Principles outpatient anesthesia

Question 1

Advantages of outpatient anesthesia

Answer 1

Financial, medical, patient satisfaction, social, staffing.

Question 2

Disadvantages of outpatient anesthesia

Answer 2

Less patient privacy than in the inpatient setting.

The patient may be required to make multiple trips to the physician’s office or the ambulatory setting for preoperative evaluation and screening.

Adequate home care must be coordinated after patient discharge.

Compliance with preoperative and postoperative instructions may not be as good as when patient is in the inpatient setting.

Question 3

Demographic considerations

Answer 3

Patient Age:
Patients of any age can undergo outpatient surgical procedures

Surgical Time:
Arbitrarily limiting expected surgical times to 2 hours is no longer considered necessary

Suitable Procedures:
Constantly evolving

Question 4

Patient selection

Answer 4

Proper patient selection reduces number of hospital admissions after outpatient surgery

Primary predictors of hospital admission are related to:
The type of surgical procedure, subsequent complications, PONV, pain, significant operative fluid shifts or blood loss

Factors to consider when determining if a patient is suitable for outpatient surgery:
The anticipated surgical procedure, the physical and psychosocial health of the patient, the surgeon’s skill and cooperation

Question 5

Primary predictors of hospital admission are related to:

Answer 5

The type of surgical procedure

Subsequent complications:
PONV
Pain
Significant operative fluid shifts or blood loss

Question 6

Factors to consider when determining if a patient is suitable for outpatient surgery:

Answer 6

The anticipated surgical procedure

The physical and psychosocial health of the patient

The surgeon’s skill and cooperation

Question 7

Premature infant (gestational age 37 weeks or less at birth):

Answer 7

Inappropriate for outpatient surgery because of potential physiologic aberrations:

Anemia

Gag reflexes not fully developed leading to increased risk of aspiration

Immature temperature regulation

Immature brainstem function, increasing risk of pathologic respiratory conditions

Question 8

Acute Substance Abuse:

Answer 8

Urine drug screen if drug use suspected

If acute substance abuse, reschedule

Question 9

Full-term infant:

Answer 9

Healthy full-term infants may be considered for minor outpatient procedures

Not appropriate:
Hx of apneic episodes
Failure to thrive
Feeding difficulties
Respiratory difficulties at birth

Question 10

Geriatric patients (> 65 years old):

Answer 10

Individualized, based on physiologic age (not chronologic age)

Ensure appropriate home care and transportation to/from the surgery center

Question 11

Convulsive Disorders:

Answer 11

Schedule surgery early in the day so patient can be observed 4-8 hours postoperatively

Maintain patient’s anticonvulsant schedule

Uncontrolled seizures: NOT appropriate for OPS

Question 12

Malignant Hyperthermia Susceptibility:

Answer 12

Definition:
Previous MH episode

Masseter muscle rigidity with previous anesthetic

1st degree relative with a history of MH or positive muscle biopsy

Diseases with known mutations on chromosome 19: central core myopathy, King-Denborough syndrome, Native American myopathy, and hypokalemic periodic paralysis

Patients with heat-induced rhabdomyolysis

Question 13

Morbid Obesity:

Answer 13

BMI > 35-40 no longer limited

*Thorough preoperative airway evaluation is vital

Question 14

Obstructive Sleep Apnea:

Answer 14

Instruct patient to bring CPAP machine for postoperative recovery phase

OSA patients with nonoptimized comorbid medical conditions may not be good candidates for OPS

Question 15

Reactive Airway Disease:

Answer 15

Patient should be medically optimized

Question 16

Sickle Cell Disease:

Answer 16

Criteria:

No major organ disease due to sickle cell

No sickle cell crisis within last year

Patient must be compliant with prescribed medical care

Patient should reside within 15 minutes of a facility prepared to care for him/her

Patient should receive close follow-up postoperative care

Question 17

Social Considerations:

Answer 17

Patient compliance

Presence of responsible caregiver

Discharge accommodations

Access to assistance

Financial and insurance considerations

Question 18

Unacceptable patient conditions for ambulatory surgery:

Answer 18

Unstable ASA physical class III or IV (cardiac, renal, hepatic, endocrine, pulmonary, or cancer diagnoses)

Active substance abuse

Psychosocial difficulties (caregiver not available to observe patient the evening of surgery)

Poorly controlled seizures

Morbid obesity with significant comorbid conditions (angina, asthma, OSA)

Previously unevaluated and poorly managed moderate to sever OSA

Ex-premature infants < 60 weeks postconceptual age requiring GETA

Uncontrolled diabetes

Current sepsis or infectious disease requiring isolation facilities

Anticipated postoperative pain that will not be controlled with oral analgesics and/or local anesthesia techniques

Question 19

Thorough medical exam and history should be taken:

Answer 19

Medically stable patient: within 30 days of procedure

High-risk patients: within 72 hours of the procedure

Question 20

Chest Radiography should occur with

Answer 20

New pulmonary signs or symptoms

End-stage renal disease

Decompensated heart failure (if tests might change patient management or outcome)

Question 21

Electrocardiography:

Answer 21

Routine EKG is not required

Not cost effective and is a poor predictor of perioperative outcomes

Question 22

Pregnancy test for menstruating females under 13

Answer 22

No test unless patient sexually active or inconclusive

Question 23

Pregnancy test

Answer 23

Should be offered to all patients except those with a hysterectomy or bilateral salpingo-oophorectomy

serum test preferred, urine test sufficient

Question 24

Fasting status and aspiration risk

Answer 24

clear liquids - 2 hrs
breast mile - 4 hrs
infant formula - 6 hrs
non human milk - 6 hrs
light meals - 6 hrs
heavy meal/fried/fatty - 8 hrs

Question 25

Medications

Answer 25

Patients should continue to take any cardiopulmonary medications through the morning of surgery

Warfarin:
Early decision re: continue/discontinue/bridge with subcutaneous LMWH
-Discontinue: Stop 5 days before surgery; INR day of surgery; resume warfarin 12-24 hours postoperatively

Question 26

Heart Murmur:

Answer 26

If previously undetected, further workup is necessary

Question 27

Rhinorrhea:

Answer 27

Determine whether it is normal for the child or an illness that has recently developed
Surgery should be delayed for an infectious runny nose

Question 28

Diabetes:

Answer 28

Schedule surgery early in the day

If available, review 6-month blood glucose and/or HbA1C

HbA1C > 6.9 and/or significant comorbidities require optimization prior to surgery

Determine type/dosage/schedule of antidiabetic medication

Obtain hospitalization hx re: glycemic control issues

Instruct patient NPO after midnight if surgery is scheduled early in the day

Monitor patient’s blood glucose levels upon arrival to the surgery center

Prevent hypoglycemia while maintaining blood glucose < 180 mg/dL

Manage preoperative or and noninjectable antidiabetic medications

Patient should continue usual routine prior to the day of surgery

Withhold therapy on the day of surgery

Manage preoperative insulin therapy

Return patient to preoperative activities of daily living ASAP

Inform patient that hospital admission is possible if persistent PONV prevents normal dietary intake

Question 29

Insulin pump

Answer 29

No change day before, no change on day, use sick day or sleep basal rates

Question 30

Short, rapid, and noninsulin injectables

Answer 30

no change before, hold the day of

Question 31

intermediate acting

Answer 31

day before no change unless taken in evening, then do 75% of dose.

50-75% of morning dose on the day of

Question 32

long-acting peakless insulins

Answer 32

no change day before

75%-100% of morning dose

reduce nighttime dose if history of nocturnal or morning hypoglycemia…on the day of surgery the morning dose of basal insulin may be administered on arrival to the ambulatory center

Question 33

fixed combination

Answer 33

no change day before

50-75% of morning dose of intermediate acting component

Question 34

Considerations for postponing surgery

Answer 34

Lack of drug compliance

Postpone/Cancel surgery if patient does not follow fasting guidelines

Delay procedure until pregnancy status can be confirmed is suspicious of pregnancy

Upper respiratory tract infection (URI):
Review each case individually
Consider:
Urgency of the surgery
Duration and complexity of the surgery
Number of times the procedure has been canceled
Patient/Family wishes

Question 35

Indications for premedication:

Answer 35

Decrease patient anxiety and fear

Facilitate smooth induction and emergence from anesthesia

Supplement anesthesia and reduce need for general anesthetic agents

Reduce volume and acidity of gastric contents

PONV prophylaxis

Provide a more pleasant PACU stay

Question 36

Pulmonary Aspiration Prophylaxis:

Answer 36

Antacids:
Rapidly reduce gastric acidity; raise pH in 15-20 minutes
Disadvantage: increase gastric volume

Gastrokinetics:
i.e., Metoclopramide (Reglan)
Reduce gastric fluid volume

H₂-Receptor Antagonists:
i.e., Cimetidine, ranitidine, famotidine, nizatidine
Block hydrogen ion release by gastric parietal cells
Do not alter the pH of gastric fluid already in the stomach

Gastric Proton-Pump Inhibitors:
i.e, Omeprazole, lansoprazole, pantoprazole,

Question 37

What is the most widely used technique for ambulatory surgery?

Answer 37

General anesthesia

Should be achieved with less soluble inhalation agents and short-acting intravenous agents that can be reversed if needed

Question 38

IV insertion and perioperative fluid should be administered in the following situations

Answer 38

Procedures > 30 minutes

Procedures with increased risk of PONV

Procedures associated with postoperative discomfort

Prolonged fasting before surgery

Procedures associated with intraoperative and postoperative bleeding

Procedures requiring the administration of IV antibiotics

Question 39

Regional Anesthesia:
advantages

Answer 39

Improves pain scores

Decreases opiate use

Lowers the incidence of PONV

Shortens the recovery period

Shortens PACU stays

Question 40

Regional Anesthesia disadvantages

Answer 40

Requires cooperation of patient and surgeon

May take longer to perform than a general anesthetic

May delay time to discharge

May require additional patient postoperative education

Question 41

Persistent PONV is responsible for:

Answer 41

Delays in discharge

Increased patient costs

Unanticipated hospital admissions

Question 42

Uncontrolled postoperative pain causes:

Answer 42

Triggering of the stress response

Patient uneasiness

Neurohumoral responses

Increased nausea and vomiting

Psychological stress

Discharge delays

Unanticipated hospital admission

Question 43

Discharge criteria

Answer 43

No single universally accepted standard exists for determining discharge readiness

Question 44

The following clinical markers should be assessed in an organized and concise manner for discharge

Answer 44

Vital signs should be stable and age appropriate

The patient should be oriented x 3 (or at a level consistent with the patient’s developmental and/or preoperative status)

If ambulation assistance is required, the home caregiver should be able to meet the need

No respiratory distress

Swallowing and coughing protective airway reflexes should be present

Bleeding should be minimal or appropriate for the surgery performed

Pain should be minimal or controlled with an appropriate analgesic regimen

Nausea and vomiting should be minimal

Oral intake is not necessary prior to discharge unless vital to patient’s condition (diabetic, requiring oral analgesics, etc.)

Voiding is not mandatory except for patients at high risk of urinary retention (hx of postoperative urinary retention, pelvic/urologic procedure, perioperative catheterization)

A responsible caregiver should be available