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Spring '20/ L. BASICS- Immune, OR Hazards, OP > Outpatient Surgery > Flashcards

Outpatient Surgery Flashcards

1
Q

OP surgery centers are: (examples)

A

Ambulatory Surgical centers (ASC), Office based (OBA), stand alone, Hospital OP

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2
Q

OP Anesthesia criteria guidelines

A

Vary from Facility to facility

- should be agreed upon by surgeon, anesthesia & staff

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3
Q

OP Anesthesia criteria for types of patient

A
  • 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

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4
Q

ASC safer record than ____

A

OBA

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5
Q

An OBA or ASC must have all items required to follow:

A

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

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6
Q

Center personnel and Anesthesia are often required to be:

A

ACLS/BLS/Pals certified b/c they will serve as the primary care giver for a longer period of time

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7
Q

b/c of OP facility isolation of emergency events what should be provided to enhance staff readiness?

A

simulation exercises

**ensure they have Carts, airway tools, equipment, meds, etc.

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8
Q

OP Anesthesia criteria on Taking Pt Hx:

A

some HX is important; may discover pt is not appropriate for OP Center.

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9
Q

OP Anesthesia criteria for LABS

A

Not obtained if not necessary

- pregnancy test likely done on women of childbearing age; controversial

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10
Q

Routine EKG:

A 
>65 yrs
HX of HF
Previous MI/angina
high cholesterol
Significant valvular disease
family hx of sudden death
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11
Q

Usually no need for lab testing except:

A
  • unstable chronic dx
  • potential high blood loss (a good reason NOT to do procedure in ASC/OBA)
  • expected use of contrast dye (BUN/crt)
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12
Q

Overall; OK for Non-Hospital Environment IF:

A

-Cardiac Stable
- no entry into Spaces of:
T-thoracic
V-vascular
P-Peritoneal

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13
Q

STOP Signs on Day of Surgery: CARDIAC

A
  • 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
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14
Q

Stent criteria NOT to do OP Surgery

A
  • Drug eluting coronary stent placed w/in 1 YEAR

- bare metal stent w/in 1 month

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15
Q

Is smoking a stop reason for surgery?

A

no - we aren’t going to talk them into quitting

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16
Q

STOP if 3 or More of the Following Cardiac RF’s:

A
  • ischemic Heart disease
  • hx of chf
  • insulin dept DM
  • CRD (CR>2.0 mg/dl)
  • TIA
  • CVA
  • AICD is facility dependent
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17
Q

Creatinine level we need to know for potential surgical risk factors

A

> 2.0 mg/dl

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18
Q

STOP Signs on Day of Surgery: PULMONARY

A
  • 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
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19
Q

STOP Signs on Day of Surgery: RENAL

A
  • 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
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20
Q

Invasive Pediatric Airway surgeries should be done where?

A

Hospital based OP surgery vs Free standing

-access to ped intensivists and RT

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21
Q

Overall Goals of OP Surgery

A
  • convenience
  • low cost
  • care aligned w/pt and surgeon goals
  • safe
  • diminish/eliminate Pain, PONV, PostOP cognitive impairment
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22
Q

Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

GENERAL ANESTHESIA

A

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
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23
Q

Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

GENERAL INTRAVENOUS

A

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
24
Q

Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

REGIONAL

A

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
25
Q

Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

MAC

A

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
26
Q

Comorbid Conditions associated w/OSA

TBL 37.4

A 
HTN
Arrhythmias
Cor pulmonale
Ischemic Heart disease
DM
CVA
Daytime sleepiness
Depression
Decreased vitality and social funtioning on SF-36 (reduced quality of life)
27
Q

Disease related potential complications associated w/OSA:

TBL 37.4

A 
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
28
Q

Characteristics that may Increase OSA”

TBL 37.4

A 
Down Syndrome
NM disease
CP
hx of difficult intubation
enlarged tongue or tonsil size
29
Q

STOP BANG

and scoring

A 
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
30
Q

HbA1C

A 
gives indication of how well the DM is being controlled over time
-erythrocytes 120 day lifespan
-norm <6%
- levels <7% considered controlled
-
31
Q

How much of a reduction in insulin should you make day of surgery to prevent hypoglycemia d/t fasting?

A

30-50%

32
Q

Biguanide example

A

Metformin

33
Q

Metformin should be stopped how many hours pre-op?

Why?

A

48

*reduce risk of Fatal Lactic Acidosis

34
Q

S/S of Biguanide induced lactic acidosis are:

A 
nonspecific and include:
anorexia
n/v
AMS
hyperpnea (rapid deep breathing)
abd pain
thirst
*Presenting with ACIDOSIS (w/o hypoperfusion or hypoxia)
35
Q

TX of biguanide -induced lactic acidosis:

A

withdrawal of biguanide
adequate hydration/circulatory support
correction of acidosis
HD (for acid/base control; drug clearance)

36
Q

Explain 1800 Rule

A

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

37
Q

Preferred method of insulin administration?

A

SubQ

  • slower, steady control
  • avoid wide swings in glucose levels
  • will see IV used
38
Q

Patients with treated HTN who undergo surgery have as much as 50% increased risk….

A

of MI / cardiac arrest or significant new dysrhthmia in the first 30 days post-op

39
Q

ACE inhibitors are associated with ____ a

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)

40
Q

ACEI and Angiotensin II receptro subtype -1 antagonists (Cozaar, Diovan) should be d/c’d within how many hours of induction?

A

10 hours

41
Q

To treat profound hypotension in GA from ACE inhibitors, what would you do?

A

Vasopressin 0.4-0.8mcg (1-2 units –> 1unit/ml)

**if vasopressin not working –> methylene blue

42
Q

Important factors to monitor for pt who’s been on antihypertensives

A
  • EKG
  • Trends (bp, hr, etc)
  • keep BP w/in 20% of baseline
43
Q

OP center concerns for Morbidly Obese patients

A
  • 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
44
Q

airway, cardiopulmonary, and endocrine evaluations are appropriate for patients with a BMI :

A

> 35 kg/m2

45
Q

What creates sympathetic neural activation and leads to HPTN and CV abnormalities that can cause morbidity and sudden death?

A

OSA

46
Q

A Hospital setting is more appropriate for this type of patient:

A

Appears or is known to have moderate or severe OSA and is UNTREATED and will require opioids for pain.

47
Q

** Upper Respiratory Infection **

Airflow obstruction has been shown to be persist for how many weeks in adults?

A

up to 6 weeks

therefore surgery should be delayed 6 weeks from onset of URI

48
Q

** Upper Respiratory Infection **

When would you delay a surgery in Children with URI?

A

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

49
Q

Risk Factors for adverse respiratory events in children with URI’s include:

A
  • 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
50
Q

It’s generally appropriate to proceed with planned procedure if a pt with URI does not have:

A

a FEVER (101 + no surgery)

51
Q

Prevention of PONV is best by

A

Increasing fluids

adults immediate post-op should receive 20ml/hr of LR for each hour fasted over 20 mins.

52
Q

Different modes of medication to prevent PONV

A

zofran, decadron (dexamethasone), reglan, scopolamine

  • if still n/v post-op, phenergan 6.25mg IV
  • Doperidol (B.Box warning for enlongated QTC)
53
Q

Concerns with giving Phenergan IV?

A

infiltration - tissue damage

sedation in higher doses

54
Q

This combination decreases PONV in pediatrics by 80%:

A

hydration a dual prophylaxis with Zofran and dexamethasone

*repeated doses of zofran in adults were less effective (promethazine!)

55
Q

Patients place a high value on the prevention of PONV ranking it equivalent to prevention and tx of ____.

A

Pain

56
Q

Scoring system used to direct prophylaxis against PONV

A

Apfel’s

Spring '20/ L. BASICS- Immune, OR Hazards, OP (18 decks)

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