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AS - N931 Advanced Principles of Anesthesia > Outpatient Surgery > Flashcards

Outpatient Surgery Flashcards

1
Q

Patient, Procedure, & Practitioner Selection

A

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

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2
Q

Safety Supplies

A 
Code cart
MH - Dantrolene or Ryanodex
LAST
Difficult airway \$\$$
- Gold standard = fiberoptic
RNs ACLS & PALS certified
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3
Q

Outpatient Surgery Advantages

A

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

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4
Q

Outpatient Surgery Disadvantages

A

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

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5
Q

Patient Seletion

A

Healthy & optimized

Stable 3mos prior to surgery

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6
Q

Inappropriate Patients

A

Acute substance abuse - acute intoxication

Premature infant < 60wks corrected

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7
Q

Seizure Disorder

A

Schedule early in day to observe 4-8 hours postop

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8
Q

Cystic Fibrosis

A

Protective airway measures

GERD & pulmonary aspiration risk

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9
Q

Malignant Hyperthermia

A 
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
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10
Q

Obesity

A

↑adverse postop outcomes

BMI > 45 kg/m^2

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11
Q

Obstructive Sleep Apnea

A

Bring CPAP

Minimize benzodiazepine & opioid use

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12
Q

Preoperative Testing

A 
EKG > 65yo or ASA class III
Routine testing NOT necessary unless history sudden family death, potential blood loss, contrast dye, or potential pregnancy
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13
Q

CBC

A

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

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14
Q

Coagulation

A

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

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15
Q

Liver Function

A

Cirrhosis

Acute hepatic history

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16
Q

Pulmonary Function

A

Asthma management

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17
Q

Urine Analysis

A

Hardware insertion

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18
Q

Type & Screen

A

Anticipated blood loss >500mL

Rhogam

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19
Q

Electrolytes

A

Recent medication changes that affect potassium or electrolytes

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20
Q

Creatinine

A

Contrast dye study

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21
Q

Glucose

A

DOS

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22
Q

When should high risk patients be evaluated for ambulatory surgery?

A

At least 1 week prior to surgery

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23
Q

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

A

6 months

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24
Q

Most common ambulatory surgery center procedures are _____ & _____

A

Endoscopy

Opthalmologic

25
Q

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

A

24 hour observation

26
Q

Routine procedures performed at ASCs

A
  • Lap chole
  • Lumbar laminectomy
  • Cervical laminectomy & fusion
  • Total joint arthroplasty
  • Select bariatric surgeries
27
Q

When to cancel a case?

A 
Acute illness
Untreated or worsening chronic disease state
Non-compliance
NPO status
Pregnancy suspicion
URI
28
Q

Pulmonary Aspiration

RISK FACTORS

A 
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
29
Q

NPO Status

A 
Clear liquids = 2 hours
Breastmilk = 4 
Infant formula = 6
Non-human milk = 6
Light meal = 6
Heavy meal (fried or fatty) = 8
30
Q

Cardiac Disease

A

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 ?

31
Q

Pulmonary Disease

A

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

32
Q

Renal Disease

A

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

33
Q

Unstable Patient Conditions

A 
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
34
Q

Anesthesia Types

A 
Avoid opioids & narcotics
Multi-modal pain analgesia approach
Regional (blocks, epidural, or spinal) + general
TIVA > volatile anesthetics
PONV prophylaxis
35
Q

Who can provide MAC?

A

Only anesthesia providers

36
Q

Monitored Anesthesia Care

RISKS

A 
Able to maintain own airway
Always prepare for general anesthesia
Over-sedation → apnea
Hypoventilation & relative hypoxemia
Airway fire risk
37
Q

Neuraxial Anesthesia

Advantages

A 
↓anesthesia time
↓turnover
Shortened PACU discharge
Enhanced postop recovery
Pain management
↓PONV
38
Q

General Anesthesia

RISKS

A 
↑PONV risk
Airway injury
Hypothermia
Postop cognitive dysfunction
Delayed discharge
TIVA prevents risks associated w/ volatile anesthetics
Avoid ETT intubation
Multi-modal anesthesia ↓opioids
39
Q

What HbA1c level indicates adequate blood glucose control?

A

< 7%

Ideal candidates for elective outpatient surgery

40
Q

Insulin Pump

A

No change day before or DOS

Utilize “sick day” or “sleep” basal rates

41
Q

Long-Acting Insulins

A

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

42
Q

Intermediate-Acting Insulins

A

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

43
Q

Fixed Combination Insulins

A

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

44
Q

Short & Rapid-Acting Insulin

A

No change day before surgery

Hold morning dose DOS

45
Q

Fast-Tracking

A 
Bypass 1st stage PACU & proceed directly to phase 2
- Do not require airway support
- Stable cardiopulmonary status
- Adequate analgesia
↓cost
46
Q

Hypertension

A

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

47
Q

Malignant Hyperthermia

Treatment

A

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

48
Q

Morbid Obesity

A

↑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

49
Q

OSA

A

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

50
Q

Ambulatory Surgical Centers vs.

Office-Based Anesthesia

A

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

51
Q

Multi-Modal Analgesics

A 
Gabapentin
COX-2 inhibitors
Ketamine
β blockers
Ketorolac
Magnesium
Dexamethasone
Lidocaine
52
Q

Pediatric Patients

A

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

53
Q

Rhinorrhea

A

20-30%

Children < 2yo prone to 5-10 viral respiratory infections annually

54
Q

Rhinorrhea Differential Diagnoses

A 
Viral infection
Nasopharyngitis
Contagious disease
Acute bacterial infection
Streptococcal tonsillitis
Meningitis (delay 2wks; ideal 4-6wks)
55
Q

PONV Apfel Score

A

Useful predictor to prevent PONV in PACU 1st 24hrs

Poor predictor 24-72hrs after discharge

56
Q

Scopolamine Patch

A

Wash hands after removing

Wear gloves when placing

57
Q

URI

Complications

A

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

58
Q

Postop Complications

A

Optimize preop
Prevent prolonged cases
PONV prophylaxis
Monitor outcomes

59
Q

Discharge Criteria

A 
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)

AS - N931 Advanced Principles of Anesthesia (17 decks)

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