OUTPATIENT SURGERY Flashcards
OUTPATIENT ANESTHESIA CRITERIA- is there a specific list of acceptable patients
NO SINGLE LIST OF ACCEPTABLE PATIENTS OR CASES WORK FOR EVERY ASC OR OFFICE BASE ANESTHESIA (OBA)
what are the guidelines for outpatient surgery? (trick question)
guideline vary from facility to facility
who agrees on the outpatient criteria (3)
should be agreed upon by surgeon, anesthesia, and staff,
we look at 3 things to determine outpatient criteria
how close office or ASC is to tertiary care facility
community resources (type of hospital and asc or oba)
TYPES OF PATIENT WILL DEPEND ON AFFILIATION (HOSPITAL) OR FREE STANDING FACILITY (EX: CARDIAC PATIENTS, CO-MORBIDITIES, PEDIATRICS)
PREVENTION OF PONV
INCREASED FLUIDS
DURING IMMEDIATE PRE-OP PERIOD ADULT PATIENT SHOULD RECEIVE what rate of fluids over how long?
2 cc/HR OF LR FOR EACH HOUR FASTED TO BE INFUSED OVER 20 MINUTES.
DIFFERENT MODES OF MEDICATIONS: for PONV
ZOFRAN, DECADRON, REGLAN, SCOPOLAMINE
HYDRATION WITH ZOFRAN AND DECADRON DECREASES PONV IN PEDIATRICS BY
80%
IF STILL N/V POST-OP:
PHENERGAN SMALL DOSE 6.25 MG IV
Know about decadron
Phenergan- phlebitis-
decadon 8mg- although recent literature says 4-5mg is sufficient.
GENERALLY IF A PATIENT WITH A URI HAS A NORMAL APPETITE, DOES NOT HAVE A FEVER OR AN ELEVATED RESPIRATORY RATE, AND DOES NOT APPEAR TOXIC. Do we proceed with procedure??
IT IS PROBABLY SAFE TO PROCEED WITH THE PLANNED PROCEDURE.
INDEPENDENT RISK FACTORS FOR ADVERSE RESPIRATORY EVENTS IN CHILDREN WITH URIs INCLUDE (7)
USE OF ETT (vs) LMA OR FACE MASK HISTORY OF PREMATURITY HISTORY OF REACTIVE AIRWAY DISEASE HISTORY OF PARENTAL SMOKING SURGERY INVOLVING THE AIRWAY PRESENCE OF COPIOUS SECRETIONS NASAL CONGESTION
do we cancel for runny nose?
do we cancel for green secretions?
not for running noose but take care of green secretion prior to surgery
IF PATIENT APPEARS OR IS KNOWN TO HAVE MODERATE OR SEVERE OSA AND IS UNTREATED, ARE THEY APPROPRIATE FOR OUTPATIENT SETTINGS? What do we give them to make things worse
WILL REQUIRE OPIOIDS FOR PAIN, A HOSPITAL SETTING IS MORE APROPRIATE
HOW IS A OSA BEST TREATED PRIOR TO OUTPATIENT SURGERY
BEST SERVED BY A SLEEP STUDY AND CPAP THERAPY FOR A FEW WEEKS.
ONCE PATIENTS ARE TREATED OUTPATIENT WITH CPAP THERAPY AND A SLEEP STUDY WHAT DOES IT IMPROVE(3) THINGS
IT IMPROVES CARDIAC FUNCTION
DIMINISH HPTN: LESS BLEEDING
POTENTIALLY DECREASE THE SIZE OF THE TONGUE AND HYPOPHARYNGEAL MUSCLES: EASIER AIRWAY MANAGEMENT
VIRAL DELAYING FOR CHILDREN?
In childen you have 2 weeks-
length of VIRAL DELAYING FOR ADULTS
Surgery should be delayed 6 weeks if they have had a viral respiratory infection
WHY IS IT IMPORTANT TO DIAGNOSE OSA PRIOR TO SURGERY? (5) COMPLICATIONS
CVA MI BLEEDING PERI-OPERTIVE RESPIRATORY EVENTS DIFFICULT INTUBATIONS
OSA IS THE MAJORITY DIAGNOSED?
MAJORITY OF OSA REMAIN UNDIAGNOSED
OSA WHAT DOES IT CREATE? AND LEAD TO? AND CAN CAUSE?
CREATES SYMPATHETIC NEURAL ACTIVATION AND LEADS TO HPTN AND CV ABNORMALITIES THAT CAN CAUSE MORBIDITY AND SUDDEN DEATH
MORBID OBESITY
INCREASE CO-MORBIDITY
OSA
NEED REFERRAL FOR AIRWAY, PULMONARY & SLEEP DISORDER
AIRWAY, CARDIOPULMONARY, AND ENDOCRINE EVALUATIONS ARE APPROPRIATE FOR BMI > 35 KG/M2. ON-SITE EVAL OF AIRWAY FOR INTUBATION IS IMPERATIVE
Low FRC- MORBID OBESITY- DO WE WANT THEM IN THE OUTPATIENT SETTING??
outpatient really doesn’t have the greatest ventilators. Not the people you want to prone-airway issues- their airways have redundant tissue- it will fold around their blades. Morbidly obese- outpatient setting housed inpatient settings- 35 on BMI- think about if they really need to be in a free standing outpatient.
patient with hypertension being treated with antihypertensive-WHAT IS A PATIENTS % INCREASED RISK OF MI, CARDIAC ARREST, OR A SIGNIFICANT NEW DYSRHYTHMIAS IN THE FIRST 30 DAYS AFTER THEIR PROCEDURE
50%
ACE INHIBITORS ASSOCIATED WITH
PROFOUND HYPOTENSIVE AFTER GENERAL INDUCTION.
ACE INHIBITORS WHAT ARE THESE PATIENTS POST OP MORBIDITY AND MORTALITY RATES
THESE PATIENT CAN GO ON TO HAVE A SIGNIFICANT INCREASE IN POST-OP MORBIDITY AND MORTALITY RATES
ACEI AND ANGIOTENSIN II RECEPTOR SUBTYPE-1 ANTAGONIST (ARA) SHOULD BE D/C’ed WITHIN ____HRS PRIOR TO GENERAL SURGERY. NAME 2 EXAMPLES?
10 HOURS OF INDUCTION FOR GENERAL SURGERY. ( ARA EX: COZAAR, DIOVAN)
Push vaso pressin for ace inhibitors HYPOTENSION.
WHAT IS THE DOSE?
1-2units/cc
THE 1800 RULE
DIVIDE YOUR TOTAL DAILY INSULIN DOSE INTO 1800 IN ORDER TO CALCULATE HOW MANY POINTS OF GLUCOSE WILL BE LOWERED BY 1 UNIT OF RAPID ACTING INSULIN
ONCE YOU HAVE GIVEN INSULIN- HOW LONG DO YOU WAIT TO RECHECK
30 MINUTES
IF BLOOD SUGAR HAS DECREASED WHAT DO YOU DO?
CONTINUE SURGERY
WHAT DOES THE BOOK SAY ABOUT HOW TO DELIVER INSULIN
THE BOOK SAYS GIVE INSULIN SUB Q
IN CLINIC HOW DO WE DELIVER THE INSULIN
IV
1800 RULE EXAMPLE
PATIENTS TOTAL DOSE IS 20 UNITS/DAY
DIVIDE 1800 BY 20=90
WE EXPECT THE INSULIN TO DECREASE 90MG/DL PER 1 UNIT OF INSULIN
TREATMENT biguanide-induced lactic acidosis
adequate hydration/circulatory support and correction of the acidosis. Hemodialysis may be useful for both acid/base control and drug clearance.
Signs and symptoms of biguanide-induced lactic acidosis
nonspecific and include anorexia, nausea, vomiting, altered level of consciousness, hyperpnea (rapid deep breathing), abdominal pain thirst. Should suspect lactic acidosis in patients presenting with acidosis, but without evidence of hypoperfusion or hypoxia.
WHAT DOES HBA1C TELL US
HbA1C GIVES AN INDICATION OF HOW WELL THE DIABETES IS BEING CONTROLLED OVER TIME.
HBA1C- LIFESPAN OF ERYTHROCYTES?
BECAUSE ERYTHROCYTES NORMALLY HAVE 120-DAY LIFESPAN
NORM HBA1C
<6% HOWEVER, LEVELS <7% ARE CONSIDERED TO BE IN EXCELLENT CONTROL
WHAT HAPPENS WHEN WE REDUCE INSULIN BY 30-50% DAY OF SURGERY
MAY PREVENT HYPOGLYCEMIA DUE TO FASTING
BIGUANIDES SUCH AS METFORMIN SHOULD BE D/C’D WHEN?
IS IT CONTROVERSIAL?
NEEDS TO BE D/C 48 HOURS PREOPERTIVELY (FATAL LACTIC ACIDOSIS) “controversial”
If you have someone with an a1c of 13- WHAT DO YOU DO?
cancel surgery- get follow up for the patient.
CONCERNS WITH REGIONAL SURGERY
HIGH SPINAL
OUT PATIENT SURGERY TECHNIQUES
MAC
REGIONAL
GENERAL
OVER ALL GOALS FOR OUTPATIENT SURGERY
CONVENIENCE
LOW-COST
CARE ALIGNED WITH PATIENT AND SURGEON GOALS
SAFE
DIMINISH/ELIMINATE PAIN
DIMINISH/ELIMINATE PONV
DIMINISH/ELIMINATE POSTOP PROLONGED COGNITIVE IMPAIRMENT
CAN WE DO FISTULAS OUTPATIENT?
NO, NEVER EVER EVER
ASA 3 IN OR OUTPATIENT
INPATIENT
STOP SIGNS ON DAY OF SURGERY-renal
ELEVATED CREATININE LEVELS ESPECIALLY WITH OTHER CO-MORBIDITIES
AVFISTULAS
ARTERIOVENOUS FISTULAS (CREATION OR REVISION) AND UNSTABLE RENAL FAILURE ARE EACH ASSOCIATED WITH A HIGH MORBIDITY RATE AND ARE NOT GOOD CANDIDATES FOR SURGERY IN A FREE STANDING OUTPATIENT FACILITY
STOP SIGN DAY OF SURGERY PULMONARY: (3)
STOP IF PATIENT IS STILL WHEEZING AFTER MAXIMUM SUFFICIENT THERAPY. ESPECIALLY IF SYMPTOMATIC.
IF UNABLE TO CLIMB FLIGHT OF STAIRS WITHOUT DYSPNEA.
PULMONARY HYPERTENSION
WHAT TYPE OF SETTING IS BETTER FOR PULMONARY STOP SIGNS
THESE MAY BE APPROPRIATE FOR HOSPITAL BASED OUT PATIENT SURGERIES (vs) FREE STANDING.
INVASIVE PEDIATRIC AIRWAY SURGERY IS MORE APPROPRIATE FOR WHAT TYPE OF SETTING?
MORE APPROPRIATE FOR HOSPITAL BASED OUT PATIENT SURGERIES (vs) FREE STANDING WHERE MORE PEDIATRIC INTENSIVISTS AND RESPIRATORY THERAPY ARE AVAILABLE.
WHAT IS IMPORTANT TO CONSIDER IN PATIENTS WITH AICD OR PACERS?
SOME FACILITIES MAY NOT ADMIT PATIENTS WITH AICD AND/OR PACERS (UNLESS INTERROGATION SERVICES AVAILABLE)
STOP SIGNS ON DAY OF SURGERY: STOP IF 3 OR MORE OF THE FOLLOWING (6 TOTAL)
ISCHEMIC HEART DISEASE HISTORY OF CHF INSULIN-DEPENDENT DIABETES CHRONIC RENAL INSUFFICIENCY (Cr > 2.0 mg/dl) A TRANSIENT ISCHEMIC ATTACK CVA
STOP SIGNS ON DAY OF SURGERY CARDIAC DISEASE:
UNSTABLE ANGINA
LABILE HPTN
SEVERE VALVULAR DISEASE CARDIAC DYSRHYTHMIAS
MI WITH IN 3 MONTHS WITH CP OR AT RISK MYOCARDIUM; DRUG-ELUTING CORONARY STENT (DES: RELEASES MEDS FOR PREVENTING CELL PROLIFERATION) PLACED WITHIN 1 YEAR
BARE METAL STENT WITHIN 1 MONTH;
USUALLY NO NEED FOR LAB TESTING EXCEPT:
UNSTABLE CHRONIC DISEASE
POTENTIAL HIGH BLOOD LOSS (A GOOD REASON NOT TO DO PROCEDURE IN ASC/OBA)
EXPECTED USE OF CONTRAST DYE (BUN/Cr)
OK FOR NON HOSPITAL ENVIRONMENT IF AVOIDANCE OF WHAT 3 AREAS AND WHAT TYPE OF STABILITY
NO ENTRY INTO THORACIC, PERITONEAL, OR VASCULAR SPACES
CARDIAC STABLE
OUTPATIENT ANESTHESIA CRITERIA, IS PRE-OP ASSESSMENT STILL COMPLETED?
SAME HISTORY TAKING IS IMPORTANT. JUST BECAUSE IT IS A MINOR PROCEDURE OR SURGERY DOES NOT NEGATE THE NEED FOR AN APPROPRIATE PRE-OP ASSESSMENT
OUTPATIENT ANESTHESIA CRITERIA: LABS:
PREGNANCY TEST?
NOT OBTAINED IF NOT NECESSARY. PREGNANCY TEST IS STILL CONTROVERSIAL. HOWEVER, STILL MAY BE OBTAINED ON CHILD BEARING WOMEN
ROUTINE EKG
> 65 YEARS; HISTORY OF CHF; PREVIOUS MI; ANGINA; HIGH CHOLESTEROL; SIGNIFICANT VALVULAR DISEASE; FAMILY Hx OF SUDDEN DEATH
WHAT DO OUTPATIENT FACILITIES NEED TO DO TO MAINTAIN COMPETENCIES
BECAUSE OF THE ISOLATION OF THESE TYPES OF FACILITIES, SIMULATION EXERCISES SHOULD PROVIDED TO ENHANCE READINESS
WHAT CERTS DO OUTPATIENT SURGERY CENTER STAFF NEED TO MAINTAIN?
WHY IS IT IMPORTANT THAT THESE ARE MAINTAINED??
FREE STANDING CENTERS NURSING PERSONNEL AND ANESTHESIA SUPPORT ARE OFTEN REQUIRED TO BE BLS/ACLS/PALS CERTIFIED BECAUSE THEY WILL SERVE AS A PRIMARY CARE GIVER FOR A LONGER PERIOD OF TIME WAITING ON TRANSPORT (vs) STAFF IN OUTPATIENT IN HOSPITALS WHERE TERTIARY CARE IS READILY AVAILABLE.
ASC OR OBA- WHO IS SAFER?
HISTORICALLY, ASC SAFER RECORD THAN OBA
WHAT DO WE NEED TO MAKE SURE ASC OR OBA HAVE?
ASC AND OBA NEEDS TO BE MORE REPLETE WITH ON-SITE SUPPORT SYSTEMS THAN AN OUTPATIENT SURGICAL DEPARTMENT LOCATED WITHIN A TERTIARY CARE HOSPITAL
EXAMPLES OF WHY OBA OR ASC NEED TO HAVE ALL NECESSARY SUPPLIES ON HAND.
EX: AN OBA OR ASC MUST HAVE ALL ITEMS REQUIRED TO FOLLOW THE ASA GUIDELINE ON THE MANAGEMENT OF A DIFFICULT AIRWAY. WHERE AS A HOSPITAL OUT PATIENT DEPT (HOPD) MAY NOT REQUIRE SUCH EQUIPMENT SINCE RESOURCES OF IN PATIENT OR IS JUST STEPS AWAY.
OUTPATINET SURGERY POST MI
WAIT 6MO
outpatient surgery drug eluding stent/bar metal stent
DES-12mo
BMS-1mo
what medication is quick acting, rapid resolving for transurethral procedures in elderly males without delaying discharge
spinal bupivacaine 4mg with 20mcg of fentanyl
neural axial anesthesia for outpatient knee arthroscopy
7.5mg of 0.5% hyperbaric ropivacaine for 2.5-3.5hrs
name 3 spinal drugs that are great for shorter procedures such as knee arthroscopy and inguinal hernia repair
lidocaine, mepivacaine, 2-chloroprocaine.
characteristics that may increase OSA
down sndrome neuromuscular disease cerebral palsy history of difficult intubation enlarged tongue or tonsil size
disease related potential complications of OSA
difficult mask ventilation difficult intubation oxygen desaturation and hypoxemia exacerbation of cardiac comorbid condition delayed extubation risk of reintubation prolonged recovery room stay hypoxic brain injury death
comorbid conditions
hypertension arrhythmias cor pulmonale ischemic heart disease diabetes stroke daytime sleepiness depression decrease vitality and social functioning
