OUTPATIENT SURGERY

Question 1

OUTPATIENT ANESTHESIA CRITERIA- is there a specific list of acceptable patients

Answer 1

NO SINGLE LIST OF ACCEPTABLE PATIENTS OR CASES WORK FOR EVERY ASC OR OFFICE BASE ANESTHESIA (OBA)

Question 2

what are the guidelines for outpatient surgery? (trick question)

Answer 2

guideline vary from facility to facility

Question 3

who agrees on the outpatient criteria (3)

Answer 3

should be agreed upon by surgeon, anesthesia, and staff,

Question 4

we look at 3 things to determine outpatient criteria

Answer 4

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)

Question 5

PREVENTION OF PONV

Answer 5

INCREASED FLUIDS

Question 6

DURING IMMEDIATE PRE-OP PERIOD ADULT PATIENT SHOULD RECEIVE what rate of fluids over how long?

Answer 6

2 cc/HR OF LR FOR EACH HOUR FASTED TO BE INFUSED OVER 20 MINUTES.

Question 7

DIFFERENT MODES OF MEDICATIONS: for PONV

Answer 7

ZOFRAN, DECADRON, REGLAN, SCOPOLAMINE

Question 8

HYDRATION WITH ZOFRAN AND DECADRON DECREASES PONV IN PEDIATRICS BY

Answer 8

80%

Question 9

IF STILL N/V POST-OP:

Answer 9

PHENERGAN SMALL DOSE 6.25 MG IV

Question 10

Know about decadron

Phenergan- phlebitis-

Answer 10

decadon 8mg- although recent literature says 4-5mg is sufficient.

Question 11

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??

Answer 11

IT IS PROBABLY SAFE TO PROCEED WITH THE PLANNED PROCEDURE.

Question 12

INDEPENDENT RISK FACTORS FOR ADVERSE RESPIRATORY EVENTS IN CHILDREN WITH URIs INCLUDE (7)

Answer 12

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

Question 13

do we cancel for runny nose?

do we cancel for green secretions?

Answer 13

not for running noose but take care of green secretion prior to surgery

Question 14

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

Answer 14

WILL REQUIRE OPIOIDS FOR PAIN, A HOSPITAL SETTING IS MORE APROPRIATE

Question 15

HOW IS A OSA BEST TREATED PRIOR TO OUTPATIENT SURGERY

Answer 15

BEST SERVED BY A SLEEP STUDY AND CPAP THERAPY FOR A FEW WEEKS.

Question 16

ONCE PATIENTS ARE TREATED OUTPATIENT WITH CPAP THERAPY AND A SLEEP STUDY WHAT DOES IT IMPROVE(3) THINGS

Answer 16

IT IMPROVES CARDIAC FUNCTION

DIMINISH HPTN: LESS BLEEDING

POTENTIALLY DECREASE THE SIZE OF THE TONGUE AND HYPOPHARYNGEAL MUSCLES: EASIER AIRWAY MANAGEMENT

Question 17

VIRAL DELAYING FOR CHILDREN?

Answer 17

In childen you have 2 weeks-

Question 18

length of VIRAL DELAYING FOR ADULTS

Answer 18

Surgery should be delayed 6 weeks if they have had a viral respiratory infection

Question 19

WHY IS IT IMPORTANT TO DIAGNOSE OSA PRIOR TO SURGERY? (5) COMPLICATIONS

Answer 19

CVA
MI
BLEEDING
PERI-OPERTIVE RESPIRATORY EVENTS
DIFFICULT INTUBATIONS

Question 20

OSA IS THE MAJORITY DIAGNOSED?

Answer 20

MAJORITY OF OSA REMAIN UNDIAGNOSED

Question 21

OSA WHAT DOES IT CREATE? AND LEAD TO? AND CAN CAUSE?

Answer 21

CREATES SYMPATHETIC NEURAL ACTIVATION AND LEADS TO HPTN AND CV ABNORMALITIES THAT CAN CAUSE MORBIDITY AND SUDDEN DEATH

Question 22

MORBID OBESITY

Answer 22

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

Question 23

Low FRC- MORBID OBESITY- DO WE WANT THEM IN THE OUTPATIENT SETTING??

Answer 23

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.

Question 24

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

Answer 24

50%

Question 25

ACE INHIBITORS ASSOCIATED WITH

Answer 25

PROFOUND HYPOTENSIVE AFTER GENERAL INDUCTION.

Question 26

ACE INHIBITORS WHAT ARE THESE PATIENTS POST OP MORBIDITY AND MORTALITY RATES

Answer 26

THESE PATIENT CAN GO ON TO HAVE A SIGNIFICANT INCREASE IN POST-OP MORBIDITY AND MORTALITY RATES

Question 27

ACEI AND ANGIOTENSIN II RECEPTOR SUBTYPE-1 ANTAGONIST (ARA) SHOULD BE D/C’ed WITHIN ____HRS PRIOR TO GENERAL SURGERY. NAME 2 EXAMPLES?

Answer 27

10 HOURS OF INDUCTION FOR GENERAL SURGERY. ( ARA EX: COZAAR, DIOVAN)

Question 28

Push vaso pressin for ace inhibitors HYPOTENSION. | WHAT IS THE DOSE?

Answer 28

1-2units/cc

Question 29

THE 1800 RULE

Answer 29

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

Question 30

ONCE YOU HAVE GIVEN INSULIN- HOW LONG DO YOU WAIT TO RECHECK

Answer 30

30 MINUTES

Question 31

IF BLOOD SUGAR HAS DECREASED WHAT DO YOU DO?

Answer 31

CONTINUE SURGERY

Question 32

WHAT DOES THE BOOK SAY ABOUT HOW TO DELIVER INSULIN

Answer 32

THE BOOK SAYS GIVE INSULIN SUB Q

Question 33

IN CLINIC HOW DO WE DELIVER THE INSULIN

Answer 33

IV

Question 34

1800 RULE EXAMPLE

Answer 34

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

Question 35

TREATMENT biguanide-induced lactic acidosis

Answer 35

adequate hydration/circulatory support and correction of the acidosis. Hemodialysis may be useful for both acid/base control and drug clearance.

Question 36

Signs and symptoms of biguanide-induced lactic acidosis

Answer 36

``` 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. ```

Question 37

WHAT DOES HBA1C TELL US

Answer 37

HbA1C GIVES AN INDICATION OF HOW WELL THE DIABETES IS BEING CONTROLLED OVER TIME.

Question 38

HBA1C- LIFESPAN OF ERYTHROCYTES?

Answer 38

BECAUSE ERYTHROCYTES NORMALLY HAVE 120-DAY LIFESPAN

Question 39

NORM HBA1C

Answer 39

<6% HOWEVER, LEVELS <7% ARE CONSIDERED TO BE IN EXCELLENT CONTROL

Question 40

WHAT HAPPENS WHEN WE REDUCE INSULIN BY 30-50% DAY OF SURGERY

Answer 40

MAY PREVENT HYPOGLYCEMIA DUE TO FASTING

Question 41

BIGUANIDES SUCH AS METFORMIN SHOULD BE D/C'D WHEN? IS IT CONTROVERSIAL?

Answer 41

NEEDS TO BE D/C 48 HOURS PREOPERTIVELY (FATAL LACTIC ACIDOSIS) “controversial”

Question 42

If you have someone with an a1c of 13- WHAT DO YOU DO?

Answer 42

cancel surgery- get follow up for the patient.

Question 43

CONCERNS WITH REGIONAL SURGERY

Answer 43

HIGH SPINAL

Question 44

OUT PATIENT SURGERY TECHNIQUES

Answer 44

MAC REGIONAL GENERAL

Question 45

OVER ALL GOALS FOR OUTPATIENT SURGERY

Answer 45

CONVENIENCE LOW-COST CARE ALIGNED WITH PATIENT AND SURGEON GOALS SAFE DIMINISH/ELIMINATE PAIN DIMINISH/ELIMINATE PONV DIMINISH/ELIMINATE POSTOP PROLONGED COGNITIVE IMPAIRMENT

Question 46

CAN WE DO FISTULAS OUTPATIENT?

Answer 46

NO, NEVER EVER EVER

Question 47

ASA 3 IN OR OUTPATIENT

Answer 47

INPATIENT

Question 48

STOP SIGNS ON DAY OF SURGERY-renal

Answer 48

ELEVATED CREATININE LEVELS ESPECIALLY WITH OTHER CO-MORBIDITIES

Question 49

AVFISTULAS

Answer 49

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

Question 50

STOP SIGN DAY OF SURGERY PULMONARY: (3)

Answer 50

STOP IF PATIENT IS STILL WHEEZING AFTER MAXIMUM SUFFICIENT THERAPY. ESPECIALLY IF SYMPTOMATIC. IF UNABLE TO CLIMB FLIGHT OF STAIRS WITHOUT DYSPNEA. PULMONARY HYPERTENSION

Question 51

WHAT TYPE OF SETTING IS BETTER FOR PULMONARY STOP SIGNS

Answer 51

THESE MAY BE APPROPRIATE FOR HOSPITAL BASED OUT PATIENT SURGERIES (vs) FREE STANDING.

Question 52

INVASIVE PEDIATRIC AIRWAY SURGERY IS MORE APPROPRIATE FOR WHAT TYPE OF SETTING?

Answer 52

MORE APPROPRIATE FOR HOSPITAL BASED OUT PATIENT SURGERIES (vs) FREE STANDING WHERE MORE PEDIATRIC INTENSIVISTS AND RESPIRATORY THERAPY ARE AVAILABLE.

Question 53

WHAT IS IMPORTANT TO CONSIDER IN PATIENTS WITH AICD OR PACERS?

Answer 53

SOME FACILITIES MAY NOT ADMIT PATIENTS WITH AICD AND/OR PACERS (UNLESS INTERROGATION SERVICES AVAILABLE)

Question 54

STOP SIGNS ON DAY OF SURGERY: STOP IF 3 OR MORE OF THE FOLLOWING (6 TOTAL)

Answer 54

``` ISCHEMIC HEART DISEASE HISTORY OF CHF INSULIN-DEPENDENT DIABETES CHRONIC RENAL INSUFFICIENCY (Cr > 2.0 mg/dl) A TRANSIENT ISCHEMIC ATTACK CVA ```

Question 55

STOP SIGNS ON DAY OF SURGERY CARDIAC DISEASE:

Answer 55

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;

Question 56

USUALLY NO NEED FOR LAB TESTING EXCEPT:

Answer 56

UNSTABLE CHRONIC DISEASE POTENTIAL HIGH BLOOD LOSS (A GOOD REASON NOT TO DO PROCEDURE IN ASC/OBA) EXPECTED USE OF CONTRAST DYE (BUN/Cr)

Question 57

OK FOR NON HOSPITAL ENVIRONMENT IF AVOIDANCE OF WHAT 3 AREAS AND WHAT TYPE OF STABILITY

Answer 57

NO ENTRY INTO THORACIC, PERITONEAL, OR VASCULAR SPACES | CARDIAC STABLE

Question 58

OUTPATIENT ANESTHESIA CRITERIA, IS PRE-OP ASSESSMENT STILL COMPLETED?

Answer 58

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

Question 59

OUTPATIENT ANESTHESIA CRITERIA: LABS: PREGNANCY TEST?

Answer 59

NOT OBTAINED IF NOT NECESSARY. PREGNANCY TEST IS STILL CONTROVERSIAL. HOWEVER, STILL MAY BE OBTAINED ON CHILD BEARING WOMEN

Question 60

ROUTINE EKG

Answer 60

>65 YEARS; HISTORY OF CHF; PREVIOUS MI; ANGINA; HIGH CHOLESTEROL; SIGNIFICANT VALVULAR DISEASE; FAMILY Hx OF SUDDEN DEATH

Question 61

WHAT DO OUTPATIENT FACILITIES NEED TO DO TO MAINTAIN COMPETENCIES

Answer 61

BECAUSE OF THE ISOLATION OF THESE TYPES OF FACILITIES, SIMULATION EXERCISES SHOULD PROVIDED TO ENHANCE READINESS

Question 62

WHAT CERTS DO OUTPATIENT SURGERY CENTER STAFF NEED TO MAINTAIN? WHY IS IT IMPORTANT THAT THESE ARE MAINTAINED??

Answer 62

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.

Question 63

ASC OR OBA- WHO IS SAFER?

Answer 63

HISTORICALLY, ASC SAFER RECORD THAN OBA

Question 64

WHAT DO WE NEED TO MAKE SURE ASC OR OBA HAVE?

Answer 64

ASC AND OBA NEEDS TO BE MORE REPLETE WITH ON-SITE SUPPORT SYSTEMS THAN AN OUTPATIENT SURGICAL DEPARTMENT LOCATED WITHIN A TERTIARY CARE HOSPITAL

Question 65

EXAMPLES OF WHY OBA OR ASC NEED TO HAVE ALL NECESSARY SUPPLIES ON HAND.

Answer 65

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.

Question 66

OUTPATINET SURGERY POST MI

Answer 66

WAIT 6MO

Question 67

outpatient surgery drug eluding stent/bar metal stent

Answer 67

DES-12mo | BMS-1mo

Question 68

what medication is quick acting, rapid resolving for transurethral procedures in elderly males without delaying discharge

Answer 68

spinal bupivacaine 4mg with 20mcg of fentanyl

Question 69

neural axial anesthesia for outpatient knee arthroscopy

Answer 69

7.5mg of 0.5% hyperbaric ropivacaine for 2.5-3.5hrs

Question 70

name 3 spinal drugs that are great for shorter procedures such as knee arthroscopy and inguinal hernia repair

Answer 70

lidocaine, mepivacaine, 2-chloroprocaine.

Question 71

characteristics that may increase OSA

Answer 71

``` down sndrome neuromuscular disease cerebral palsy history of difficult intubation enlarged tongue or tonsil size ```

Question 72

disease related potential complications of OSA

Answer 72

``` 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 ```

Question 73

comorbid conditions

Answer 73

``` hypertension arrhythmias cor pulmonale ischemic heart disease diabetes stroke daytime sleepiness depression decrease vitality and social functioning ```