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Spring '20/ L. Basic's Test 3- OP, EENT, OR Hazards > OUTPATIENT SURGERY > Flashcards

OUTPATIENT SURGERY Flashcards

1
Q

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

A

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

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2
Q

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

A

guideline vary from facility to facility

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3
Q

who agrees on the outpatient criteria (3)

A

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

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4
Q

we look at 3 things to determine outpatient criteria

A

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)

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5
Q

PREVENTION OF PONV

A

INCREASED FLUIDS

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6
Q

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

A

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

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7
Q

DIFFERENT MODES OF MEDICATIONS: for PONV

A

ZOFRAN, DECADRON, REGLAN, SCOPOLAMINE

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8
Q

HYDRATION WITH ZOFRAN AND DECADRON DECREASES PONV IN PEDIATRICS BY

A

80%

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9
Q

IF STILL N/V POST-OP:

A

PHENERGAN SMALL DOSE 6.25 MG IV

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10
Q

Know about decadron

Phenergan- phlebitis-

A

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

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11
Q

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??

A

IT IS PROBABLY SAFE TO PROCEED WITH THE PLANNED PROCEDURE.

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12
Q

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

A 
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
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13
Q

do we cancel for runny nose?

do we cancel for green secretions?

A

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

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14
Q

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

A

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

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15
Q

HOW IS A OSA BEST TREATED PRIOR TO OUTPATIENT SURGERY

A

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

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16
Q

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

A

IT IMPROVES CARDIAC FUNCTION

DIMINISH HPTN: LESS BLEEDING

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

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17
Q

VIRAL DELAYING FOR CHILDREN?

A

In childen you have 2 weeks-

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18
Q

length of VIRAL DELAYING FOR ADULTS

A

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

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19
Q

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

A 
CVA
MI
BLEEDING
PERI-OPERTIVE RESPIRATORY EVENTS
DIFFICULT INTUBATIONS
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20
Q

OSA IS THE MAJORITY DIAGNOSED?

A

MAJORITY OF OSA REMAIN UNDIAGNOSED

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21
Q

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

A

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

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22
Q

MORBID OBESITY

A

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

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23
Q

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

A

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.

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24
Q

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

A

50%

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25
Q

ACE INHIBITORS ASSOCIATED WITH

A

PROFOUND HYPOTENSIVE AFTER GENERAL INDUCTION.

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26
Q

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

A

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

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27
Q

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

A

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

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28
Q

Push vaso pressin for ace inhibitors HYPOTENSION.

WHAT IS THE DOSE?

A

1-2units/cc

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29
Q

THE 1800 RULE

A

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

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30
Q

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

A

30 MINUTES

31
Q

IF BLOOD SUGAR HAS DECREASED WHAT DO YOU DO?

A

CONTINUE SURGERY

32
Q

WHAT DOES THE BOOK SAY ABOUT HOW TO DELIVER INSULIN

A

THE BOOK SAYS GIVE INSULIN SUB Q

33
Q

IN CLINIC HOW DO WE DELIVER THE INSULIN

A

IV

34
Q

1800 RULE EXAMPLE

A

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

35
Q

TREATMENT biguanide-induced lactic acidosis

A

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

36
Q

Signs and symptoms of biguanide-induced lactic acidosis

A 
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.
37
Q

WHAT DOES HBA1C TELL US

A

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

38
Q

HBA1C- LIFESPAN OF ERYTHROCYTES?

A

BECAUSE ERYTHROCYTES NORMALLY HAVE 120-DAY LIFESPAN

39
Q

NORM HBA1C

A

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

40
Q

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

A

MAY PREVENT HYPOGLYCEMIA DUE TO FASTING

41
Q

BIGUANIDES SUCH AS METFORMIN SHOULD BE D/C’D WHEN?

IS IT CONTROVERSIAL?

A

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

42
Q

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

A

cancel surgery- get follow up for the patient.

43
Q

CONCERNS WITH REGIONAL SURGERY

A

HIGH SPINAL

44
Q

OUT PATIENT SURGERY TECHNIQUES

A

MAC
REGIONAL
GENERAL

45
Q

OVER ALL GOALS FOR OUTPATIENT SURGERY

A

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

46
Q

CAN WE DO FISTULAS OUTPATIENT?

A

NO, NEVER EVER EVER

47
Q

ASA 3 IN OR OUTPATIENT

A

INPATIENT

48
Q

STOP SIGNS ON DAY OF SURGERY-renal

A

ELEVATED CREATININE LEVELS ESPECIALLY WITH OTHER CO-MORBIDITIES

49
Q

AVFISTULAS

A

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

50
Q

STOP SIGN DAY OF SURGERY PULMONARY: (3)

A

STOP IF PATIENT IS STILL WHEEZING AFTER MAXIMUM SUFFICIENT THERAPY. ESPECIALLY IF SYMPTOMATIC.

IF UNABLE TO CLIMB FLIGHT OF STAIRS WITHOUT DYSPNEA.
PULMONARY HYPERTENSION

51
Q

WHAT TYPE OF SETTING IS BETTER FOR PULMONARY STOP SIGNS

A

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

52
Q

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

A

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

53
Q

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

A

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

54
Q

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

A 
ISCHEMIC HEART DISEASE
HISTORY OF CHF
INSULIN-DEPENDENT DIABETES
CHRONIC RENAL INSUFFICIENCY (Cr > 2.0 mg/dl)
A TRANSIENT ISCHEMIC ATTACK
CVA
55
Q

STOP SIGNS ON DAY OF SURGERY CARDIAC DISEASE:

A

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;

56
Q

USUALLY NO NEED FOR LAB TESTING EXCEPT:

A

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

57
Q

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

A

NO ENTRY INTO THORACIC, PERITONEAL, OR VASCULAR SPACES

CARDIAC STABLE

58
Q

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

A

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

59
Q

OUTPATIENT ANESTHESIA CRITERIA: LABS:

PREGNANCY TEST?

A

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

60
Q

ROUTINE EKG

A

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

61
Q

WHAT DO OUTPATIENT FACILITIES NEED TO DO TO MAINTAIN COMPETENCIES

A

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

62
Q

WHAT CERTS DO OUTPATIENT SURGERY CENTER STAFF NEED TO MAINTAIN?

WHY IS IT IMPORTANT THAT THESE ARE MAINTAINED??

A

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.

63
Q

ASC OR OBA- WHO IS SAFER?

A

HISTORICALLY, ASC SAFER RECORD THAN OBA

64
Q

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

A

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

65
Q

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

A

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.

66
Q

OUTPATINET SURGERY POST MI

A

WAIT 6MO

67
Q

outpatient surgery drug eluding stent/bar metal stent

A

DES-12mo

BMS-1mo

68
Q

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

A

spinal bupivacaine 4mg with 20mcg of fentanyl

69
Q

neural axial anesthesia for outpatient knee arthroscopy

A

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

70
Q

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

A

lidocaine, mepivacaine, 2-chloroprocaine.

71
Q

characteristics that may increase OSA

A 
down sndrome
neuromuscular disease
cerebral palsy
history of difficult intubation
enlarged tongue or tonsil size
72
Q

disease related potential complications of OSA

A 
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
73
Q

comorbid conditions

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

Spring '20/ L. Basic's Test 3- OP, EENT, OR Hazards (8 decks)

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