Principles outpatient anesthesia Flashcards
Advantages of outpatient anesthesia
Financial, medical, patient satisfaction, social, staffing.
Disadvantages of outpatient anesthesia
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.
Demographic considerations
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
Patient selection
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
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
Premature infant (gestational age 37 weeks or less at birth):
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
Acute Substance Abuse:
Urine drug screen if drug use suspected
If acute substance abuse, reschedule
Full-term infant:
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
Geriatric patients (> 65 years old):
Individualized, based on physiologic age (not chronologic age)
Ensure appropriate home care and transportation to/from the surgery center
Convulsive Disorders:
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
Malignant Hyperthermia Susceptibility:
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
Morbid Obesity:
BMI > 35-40 no longer limited
*Thorough preoperative airway evaluation is vital
Obstructive Sleep Apnea:
Instruct patient to bring CPAP machine for postoperative recovery phase
OSA patients with nonoptimized comorbid medical conditions may not be good candidates for OPS
Reactive Airway Disease:
Patient should be medically optimized
Sickle Cell Disease:
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
Social Considerations:
Patient compliance
Presence of responsible caregiver
Discharge accommodations
Access to assistance
Financial and insurance considerations
Unacceptable patient conditions for ambulatory surgery:
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
Thorough medical exam and history should be taken:
Medically stable patient: within 30 days of procedure
High-risk patients: within 72 hours of the procedure
Chest Radiography should occur with
New pulmonary signs or symptoms
End-stage renal disease
Decompensated heart failure (if tests might change patient management or outcome)
Electrocardiography:
Routine EKG is not required
Not cost effective and is a poor predictor of perioperative outcomes
Pregnancy test for menstruating females under 13
No test unless patient sexually active or inconclusive
Pregnancy test
Should be offered to all patients except those with a hysterectomy or bilateral salpingo-oophorectomy
serum test preferred, urine test sufficient
Fasting status and aspiration risk
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
Medications
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
Heart Murmur:
If previously undetected, further workup is necessary
Rhinorrhea:
Determine whether it is normal for the child or an illness that has recently developed
Surgery should be delayed for an infectious runny nose
Diabetes:
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
Insulin pump
No change day before, no change on day, use sick day or sleep basal rates
Short, rapid, and noninsulin injectables
no change before, hold the day of
intermediate acting
day before no change unless taken in evening, then do 75% of dose.
50-75% of morning dose on the day of
long-acting peakless insulins
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
fixed combination
no change day before
50-75% of morning dose of intermediate acting component
Considerations for postponing surgery
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
Indications for premedication:
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
Pulmonary Aspiration Prophylaxis:
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,
What is the most widely used technique for ambulatory surgery?
General anesthesia
Should be achieved with less soluble inhalation agents and short-acting intravenous agents that can be reversed if needed
IV insertion and perioperative fluid should be administered in the following situations
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
Regional Anesthesia:
advantages
Improves pain scores
Decreases opiate use
Lowers the incidence of PONV
Shortens the recovery period
Shortens PACU stays
Regional Anesthesia disadvantages
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
Persistent PONV is responsible for:
Delays in discharge
Increased patient costs
Unanticipated hospital admissions
Uncontrolled postoperative pain causes:
Triggering of the stress response
Patient uneasiness
Neurohumoral responses
Increased nausea and vomiting
Psychological stress
Discharge delays
Unanticipated hospital admission
Discharge criteria
No single universally accepted standard exists for determining discharge readiness
The following clinical markers should be assessed in an organized and concise manner for discharge
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
