Outpatient Surgery Flashcards
Patient, Procedure, & Practitioner Selection
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
Safety Supplies
Code cart MH - Dantrolene or Ryanodex LAST Difficult airway \$\$$ - Gold standard = fiberoptic RNs ACLS & PALS certified
Outpatient Surgery Advantages
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
Outpatient Surgery Disadvantages
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
Patient Seletion
Healthy & optimized
Stable 3mos prior to surgery
Inappropriate Patients
Acute substance abuse - acute intoxication
Premature infant < 60wks corrected
Seizure Disorder
Schedule early in day to observe 4-8 hours postop
Cystic Fibrosis
Protective airway measures
GERD & pulmonary aspiration risk
Malignant Hyperthermia
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
Obesity
↑adverse postop outcomes
BMI > 45 kg/m^2
Obstructive Sleep Apnea
Bring CPAP
Minimize benzodiazepine & opioid use
Preoperative Testing
EKG > 65yo or ASA class III Routine testing NOT necessary unless history sudden family death, potential blood loss, contrast dye, or potential pregnancy
CBC
Patients w/ anemia
Surgeries or procedures w/ anticipated blood loss
Premature infants
Coagulation
Personal or family history bleeding disorders
Anticoagulants
Liver disease
Tonsillectomy & neurosurgery (controversial)
Liver Function
Cirrhosis
Acute hepatic history
Pulmonary Function
Asthma management
Urine Analysis
Hardware insertion
Type & Screen
Anticipated blood loss >500mL
Rhogam
Electrolytes
Recent medication changes that affect potassium or electrolytes
Creatinine
Contrast dye study
Glucose
DOS
When should high risk patients be evaluated for ambulatory surgery?
At least 1 week prior to surgery
How long are laboratory tests & diagnostic procedures deemed current IF patient physical condition remains stable?
6 months
Most common ambulatory surgery center procedures are _____ & _____
Endoscopy
Opthalmologic
How long should higher-risk procedure patients be monitored postop?
24 hour observation
Routine procedures performed at ASCs
- Lap chole
- Lumbar laminectomy
- Cervical laminectomy & fusion
- Total joint arthroplasty
- Select bariatric surgeries
When to cancel a case?
Acute illness Untreated or worsening chronic disease state Non-compliance NPO status Pregnancy suspicion URI
Pulmonary Aspiration
RISK FACTORS
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
NPO Status
Clear liquids = 2 hours Breastmilk = 4 Infant formula = 6 Non-human milk = 6 Light meal = 6 Heavy meal (fried or fatty) = 8
Cardiac Disease
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 ?
Pulmonary Disease
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
Renal Disease
↑creatinine w/ other comorbidities potential impact on surgery outcome
AV fistula not appropriate procedure at free-standing outpatient facility
Unstable renal failure not appropriate
Unstable Patient Conditions
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
Anesthesia Types
Avoid opioids & narcotics Multi-modal pain analgesia approach Regional (blocks, epidural, or spinal) + general TIVA > volatile anesthetics PONV prophylaxis
Who can provide MAC?
Only anesthesia providers
Monitored Anesthesia Care
RISKS
Able to maintain own airway Always prepare for general anesthesia Over-sedation → apnea Hypoventilation & relative hypoxemia Airway fire risk
Neuraxial Anesthesia
Advantages
↓anesthesia time ↓turnover Shortened PACU discharge Enhanced postop recovery Pain management ↓PONV
General Anesthesia
RISKS
↑PONV risk Airway injury Hypothermia Postop cognitive dysfunction Delayed discharge TIVA prevents risks associated w/ volatile anesthetics Avoid ETT intubation Multi-modal anesthesia ↓opioids
What HbA1c level indicates adequate blood glucose control?
< 7%
Ideal candidates for elective outpatient surgery
Insulin Pump
No change day before or DOS
Utilize “sick day” or “sleep” basal rates
Long-Acting Insulins
No peak
75-100% morning dose DOS
No change day before surgery
Reduce nighttime dose
Intermediate-Acting Insulins
Day before surgery no change in daytime dose & 75% evening dose
50-75% morning dose DOS
Fixed Combination Insulins
No change day before surgery
50-75% morning dose intermediate-acting
Lispro-Protamine use NPH instead on DOS
Short & Rapid-Acting Insulin
No change day before surgery
Hold morning dose DOS
Fast-Tracking
Bypass 1st stage PACU & proceed directly to phase 2 - Do not require airway support - Stable cardiopulmonary status - Adequate analgesia ↓cost
Hypertension
50% ↑risk MI, cardiac arrest, or dysrhythmias 30 days after procedure
ACEi → profound hypotension (refractory to drugs)
Continue ACEi & ARBs for MAC anesthesia
Malignant Hyperthermia
Treatment
Dantrolene or Ryanodex 2.5mg/kg
*Minimum 36 vials unexpired
Ice packs
Foley bladder irrigation
Morbid Obesity
↑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
OSA
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
Ambulatory Surgical Centers vs.
Office-Based Anesthesia
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
Multi-Modal Analgesics
Gabapentin COX-2 inhibitors Ketamine β blockers Ketorolac Magnesium Dexamethasone Lidocaine
Pediatric Patients
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
Rhinorrhea
20-30%
Children < 2yo prone to 5-10 viral respiratory infections annually
Rhinorrhea Differential Diagnoses
Viral infection Nasopharyngitis Contagious disease Acute bacterial infection Streptococcal tonsillitis Meningitis (delay 2wks; ideal 4-6wks)
PONV Apfel Score
Useful predictor to prevent PONV in PACU 1st 24hrs
Poor predictor 24-72hrs after discharge
Scopolamine Patch
Wash hands after removing
Wear gloves when placing
URI
Complications
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
Postop Complications
Optimize preop
Prevent prolonged cases
PONV prophylaxis
Monitor outcomes
Discharge Criteria
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)
