Outpatient Surgery Flashcards
OP surgery centers are: (examples)
Ambulatory Surgical centers (ASC), Office based (OBA), stand alone, Hospital OP
OP Anesthesia criteria guidelines
Vary from Facility to facility
- should be agreed upon by surgeon, anesthesia & staff
OP Anesthesia criteria for types of patient
- depend on affiliation (hospital) or free standing facility (ex - cardiac pts, co-morbidities, peds)
- proximity of office/ASC to a TERTIARY care facility
- Community rescources (type of hospital and ASC or OBA)
Ultimately up to you, CRNA/surgeon to determine type of pt you accept
ASC safer record than ____
OBA
An OBA or ASC must have all items required to follow:
ASA guideline on the mgmt of a difficult Airway
HOPD may not require this b/c of it’s location within higher level of care facility
Center personnel and Anesthesia are often required to be:
ACLS/BLS/Pals certified b/c they will serve as the primary care giver for a longer period of time
b/c of OP facility isolation of emergency events what should be provided to enhance staff readiness?
simulation exercises
**ensure they have Carts, airway tools, equipment, meds, etc.
OP Anesthesia criteria on Taking Pt Hx:
some HX is important; may discover pt is not appropriate for OP Center.
OP Anesthesia criteria for LABS
Not obtained if not necessary
- pregnancy test likely done on women of childbearing age; controversial
Routine EKG:
>65 yrs HX of HF Previous MI/angina high cholesterol Significant valvular disease family hx of sudden death
Usually no need for lab testing except:
- unstable chronic dx
- potential high blood loss (a good reason NOT to do procedure in ASC/OBA)
- expected use of contrast dye (BUN/crt)
Overall; OK for Non-Hospital Environment IF:
-Cardiac Stable
- no entry into Spaces of:
T-thoracic
V-vascular
P-Peritoneal
STOP Signs on Day of Surgery: CARDIAC
- unstable angina
- labile HTN
- severe valvular disease
- Cardiac Dysrhythmias
- MI w/in 3 mos WITH CP or at risk myocardium
- Drug eluting coronary stent placed w/in 1 YEAR
- bare metal stent w/in 1 month
Stent criteria NOT to do OP Surgery
- Drug eluting coronary stent placed w/in 1 YEAR
- bare metal stent w/in 1 month
Is smoking a stop reason for surgery?
no - we aren’t going to talk them into quitting
STOP if 3 or More of the Following Cardiac RF’s:
- ischemic Heart disease
- hx of chf
- insulin dept DM
- CRD (CR>2.0 mg/dl)
- TIA
- CVA
- AICD is facility dependent
Creatinine level we need to know for potential surgical risk factors
> 2.0 mg/dl
STOP Signs on Day of Surgery: PULMONARY
- pt is wheezing after max sufficient therapy
- symptomatic!
- unable to climb flight of stairs w/o SOB
- Pulmonary HTN
- these may be more appropriate for Hospital OP surgery vs. free standing
STOP Signs on Day of Surgery: RENAL
- elevated CRT especially in those w/co-morbidities (CVA, etc.)
- A/V fistulas (creation/revision)
- Unstable Renal Failure
- assoc w/High Morbidity rates and are not good candidates for free standing OP
Invasive Pediatric Airway surgeries should be done where?
Hospital based OP surgery vs Free standing
-access to ped intensivists and RT
Overall Goals of OP Surgery
- convenience
- low cost
- care aligned w/pt and surgeon goals
- safe
- diminish/eliminate Pain, PONV, PostOP cognitive impairment
Benefits and AE’s of Anesthesia Techniques (TBL 37.5)
GENERAL ANESTHESIA
BENEFITS
- NMB and intraperitoneal procedures
- Max. intraop airway control when performed with intubation
ADVERSE EFFECTS
- PONV/PDNV
- airway injury
- Cog. disfunction
- delayed d/c
- hyperalgesia
- Succinylcholine induced myalgia
- residual NMB
Benefits and AE’s of Anesthesia Techniques (TBL 37.5)
GENERAL INTRAVENOUS
BENEFITS
- Less PONV w/propofol
- NMB and intraperitoneal procedures
- Max. intraop airway control when performed with intubation
ADVERSE EFFECTS
- airway injury
- Cog. dysfunction
- delayed d/c
- hyperalgesia
- Succinylcholine induced myalgia
- residual NMB
Benefits and AE’s of Anesthesia Techniques (TBL 37.5)
REGIONAL
BENEFITS
- Prolonged postOp analgesia
- less PONV
- less risk of airway injury
- rapid recovery
- reduced exposure to anesthesia
ADVERSE EFFECTS
- local anesthetic systemic toxicity
- Peripheral nerve injury
- spinal H/A with neuraxial blockade
- equipment costs
- specialized training
- recall of operation and the associated stress
Benefits and AE’s of Anesthesia Techniques (TBL 37.5)
MAC
BENEFITS
- less exposure to anesthetic doses
- rapid recovery
- less PONV/PDNV
- low incidence of sore throat
ADVERSE EFFECTS
- minimal airway control
- pt dissatisfaction from unxpected recall
- oversedation
- operating room fires w/open system
- hypercarbia/hypoxemia
- pt discomfort
Comorbid Conditions associated w/OSA
TBL 37.4
HTN Arrhythmias Cor pulmonale Ischemic Heart disease DM CVA Daytime sleepiness Depression Decreased vitality and social funtioning on SF-36 (reduced quality of life)
Disease related potential complications associated w/OSA:
TBL 37.4
Difficult mask ventilation/ intubation O2 destauration and hypoxemia Exacerbation of cardiac comorbid conditions delayed extubation Risk of Reintubation Prolonged recovery room stay Hypoxic brain injury Death
Characteristics that may Increase OSA”
TBL 37.4
Down Syndrome NM disease CP hx of difficult intubation enlarged tongue or tonsil size
STOP BANG
and scoring
Snoring Tiredness during day Obs apnea Pressure -increased BP BMI >35kg/m^2 Age >50 Neck circ >40cm Gender male
- one point for each
- Low for OSA < 3pts
- adequate/need more testing 3-6 pts
- > = 5 pts - High likelihood for OSA
HbA1C
gives indication of how well the DM is being controlled over time -erythrocytes 120 day lifespan -norm <6% - levels <7% considered controlled -
How much of a reduction in insulin should you make day of surgery to prevent hypoglycemia d/t fasting?
30-50%
Biguanide example
Metformin
Metformin should be stopped how many hours pre-op?
Why?
48
*reduce risk of Fatal Lactic Acidosis
S/S of Biguanide induced lactic acidosis are:
nonspecific and include: anorexia n/v AMS hyperpnea (rapid deep breathing) abd pain thirst *Presenting with ACIDOSIS (w/o hypoperfusion or hypoxia)
TX of biguanide -induced lactic acidosis:
withdrawal of biguanide
adequate hydration/circulatory support
correction of acidosis
HD (for acid/base control; drug clearance)
Explain 1800 Rule
Divide total daily insulin dose into 1800
- to calculate how many points of glucose 1 unit of insulin (rapid) will lower.
- 1800/30units = 60 mg/dL
gives us an idea where to start
Preferred method of insulin administration?
SubQ
- slower, steady control
- avoid wide swings in glucose levels
- will see IV used
Patients with treated HTN who undergo surgery have as much as 50% increased risk….
of MI / cardiac arrest or significant new dysrhthmia in the first 30 days post-op
ACE inhibitors are associated with ____ a
Profound Hypotension
*many of these pts will have increased post-op morbidity/mortality rates
(30% will have problems with low BP, 10% will be resistant to other methods (Neo/Levo)
ACEI and Angiotensin II receptro subtype -1 antagonists (Cozaar, Diovan) should be d/c’d within how many hours of induction?
10 hours
To treat profound hypotension in GA from ACE inhibitors, what would you do?
Vasopressin 0.4-0.8mcg (1-2 units –> 1unit/ml)
**if vasopressin not working –> methylene blue
Important factors to monitor for pt who’s been on antihypertensives
- EKG
- Trends (bp, hr, etc)
- keep BP w/in 20% of baseline
OP center concerns for Morbidly Obese patients
- increased co-morbidity
- OSA
- Need referral for airway, pulm, and sleep d/o
- airway, cardiopulm, and endocrine evaluations are appropriate for BMI >35 kg/m2.
- Onsite airway eval imperative
airway, cardiopulmonary, and endocrine evaluations are appropriate for patients with a BMI :
> 35 kg/m2
What creates sympathetic neural activation and leads to HPTN and CV abnormalities that can cause morbidity and sudden death?
OSA
A Hospital setting is more appropriate for this type of patient:
Appears or is known to have moderate or severe OSA and is UNTREATED and will require opioids for pain.
** Upper Respiratory Infection **
Airflow obstruction has been shown to be persist for how many weeks in adults?
up to 6 weeks
therefore surgery should be delayed 6 weeks from onset of URI
** Upper Respiratory Infection **
When would you delay a surgery in Children with URI?
Cancel if symptomatic;
2 weeks may be enough
*but may develop again w/in 2 weeks.
URI has not been show to increase LOS after procedures in children
Risk Factors for adverse respiratory events in children with URI’s include:
- HX of Parental Smoking **
- Presence of Copious Secretions **
- use of ETT/LMA or Face mask
- hx of prematurity
- hx of reactive airway disease
- surgery involving the airway
- nasal congestion
It’s generally appropriate to proceed with planned procedure if a pt with URI does not have:
a FEVER (101 + no surgery)
Prevention of PONV is best by
Increasing fluids
adults immediate post-op should receive 20ml/hr of LR for each hour fasted over 20 mins.
Different modes of medication to prevent PONV
zofran, decadron (dexamethasone), reglan, scopolamine
- if still n/v post-op, phenergan 6.25mg IV
- Doperidol (B.Box warning for enlongated QTC)
Concerns with giving Phenergan IV?
infiltration - tissue damage
sedation in higher doses
This combination decreases PONV in pediatrics by 80%:
hydration a dual prophylaxis with Zofran and dexamethasone
*repeated doses of zofran in adults were less effective (promethazine!)
Patients place a high value on the prevention of PONV ranking it equivalent to prevention and tx of ____.
Pain
Scoring system used to direct prophylaxis against PONV
Apfel’s
