Test 3: Outpatient, Ambulatory, Office-Based

Question 1

What are the advantages of ambulatory and office-based surgery?

Answer 1

1) Financial: economic benefit d/t reduced medical cost & earlier return to normal
2) Medical: increased availability of hospital beds for those who require hospital admission; decreased infection risk
3) Patient satisfaction: shorter waiting times & lower costs
4) Social: minimal parent/child separation; elderly maintain normal living routines so they have decreased cognitive dysfunction
5) Staffing: more convenient location, better use of time, predictable schedules

Question 2

What are the disadvantages of ambulatory and office-based surgery?

Answer 2

-Less patient privacy
-Multiple trips to physician’s office for eval/screening
-Requires adequate home care post procedure
-Decreased compliance to pre/post op instructions
-Children do not have time to adapt to surgery environment d/t emphasis on efficiency
-Decreased observation time for adverse events
-Management of complications can be problematic

Question 3

What are the goals of Ambulatory Anesthesia?

Answer 3

-Provide fast, smooth onset of anesthesia
-Minimize anesthesia side effects
-Allow rapid offset of anesthesia by using rapid acting, short half life drugs
-Provide analgesia and amnesia
-Get patients back home on their regular eating/sleeping schedule

Question 4

What is the most common outpatient/ambulatory surgery?

Answer 4

Endoscopy of large/small intestine

Question 5

What are the primary predictors of unanticipated hospital admission?

Answer 5

-age
-frailty
-ASA status
-type of surgical procedure
-surgery complications (N/V, pain, fluid shifts)

Question 6

What factors are considered to determine suitability for outpatient/ambulatory surgery?

Answer 6

1) Anticipated surgical procedure for the patient → surgery should not have frequent complications, not have a lot of post op maintenance, not be associated with increased EBL or fluid shifts

2) Physical & psychosocial health of the patient → Pt physical status stable for at least 3 months, and medical issues not contraindicated for outpatient. Patient must have access to assistance at home/caregiver overnight

3) Surgeon’s skills/cooperation → Early referral to anesthesia for judgment of questionable patients. Take into considerations surgeon skills and speed of surgery

Question 7

List different patient populations (11) that are not appropriate for outpatient/ambulatory?

Answer 7

1) Uncontrolled seizures
2) Potential for large blood loss and large fluid shifts
3) Painful surgeries with difficult or complicated post-op course
4) Uncontrolled diabetics
5) Sepsis or infectious disease
6) Infant under 37 weeks (apnea risk) or ex-premie <60 weeks postconceptual age
7) Unstable systemic disease (ASA 3&4)
8) Psychosocial difficulties (no caregiver available post op)
9) Severe obesity w significant comorbid conditions & poorly managed OSA
10) Present drug addiction → systemic changes & need for increased post op mgmt.
-Patients often have to be admitted to hospital for pain control
11) Acute substance abuse → canceled because of impaired autonomic & CV responses as well as possible interactions w anesthesia —- ex: cocaine & ephedrine

Question 8

List questions you should ask as an anesthesia provider before working in a new ambulatory office/facility.

Answer 8

-Is the facility licensed?
-Is the facility accredited?
-Size of operating room/recovery room/preoperative area adequate for anesthesia and surgical procedures?
-Is there a transfer agreement?
-Does the facility have an emergency service agreement?
-Available communication resources?
-Patient selection criteria?
-Documentation for narcotics?

Question 9

What patient conditions should be scheduled early in the day to allow for longer post op monitoring?

Answer 9

-Sickle Cell Disease
-MH susceptibility
-Cardiac Electronic Devices
-Inc BMI
-Pediatrics/former premature infant

Question 10

What are the special considerations for patients with Sickle Cell Disease receiving outpatient/ambulatory anesthesia?

Answer 10

-Ask all African Americans
-Patients should not have had sickle cell crisis x1 yr and have no major end organ dz
-Must be followed closely post op and live within 15 min of facility that can care for them
-Test for sickle cell dz; Sickle cell trait still at risk
-Sickling can occur with hypoxia, dehydration, hypothermia, stress, pain
-Treat by keeping patient warm, well hydrated, supplemental O2, maintain high cardiac output, avoid areas of stasis w pressure or tourniquets

Question 11

What are the special considerations for patients with MH susceptibility receiving outpatient/ambulatory anesthesia?

Answer 11

-Must have 36 vials of dantrolene!!! (emergently transfer to hospital)
-Some facilities have Ryanodex (like dantrolene), which is easier to draw up
-Signs: increased HR/BP/CO2/Temp, Masseter rigidity
-Overnight observation = required for temp rise, myoglobinuria, elevated creatine kinase levels, or progression to MH episode

Question 12

What are the indications that someone is susceptible to MH?

Answer 12

-previous episode
-masseter muscle rigidity
-first degree relative with + muscle biopsy
-diseases with known mutations (chromosome 19)
-heat induced rhabdomyolysis

Question 13

What are the signs of MH?

Answer 13

increased HR/BP/CO2/Temp, Masseter rigidity

Question 14

What are the special considerations for patients with Cardiac Electronic Devices receiving outpatient/ambulatory anesthesia?

Answer 14

Know why they have the device. Underlying issues? SSS, AVB, VT, syncope. If it is for prevention of cardiac arrest, do the case in hospital!!
-Interference with cautery, ablation, and therapeutic radiation

Question 15

What is the most common source of interference with an implanted cardiac electronic device?

Answer 15

Monopolar cautery (should use bipolar instead)

Question 16

Why should you use bipolar cautery instead of monopolar with a cardiac electronic device?

Answer 16

Monopolar flow is not restricted so can go throughout the body. Pacemaker may interpret as a rhythm and inhibit pacing causing symptomatic bradycardia or may cause AICD to fire
-If use bipolar, put grounding pad below umbilicus

Question 17

What are the “rules” regarding what to have for outpatient surgery on a patient with a Pacemaker/AICD?

Answer 17

-Must have over 3 months battery life
-Magnet for surgery to apply over pacemaker (it will go in asynchronous mode at a different preset rate depending on manufacturer)
-Magnet to AICD will suspend a shock but will keep pacing
-Magnet kept on side of cart
-Listen w stethoscope when you put magnet down
-AICD should be interrogated within the last 6 months
-Pacemaker interrogation within the last year
-Important to identify in pre-op days before to get records!!

Question 18

What are the special considerations for patients with Increased BMIs receiving outpatient/ambulatory anesthesia?

Answer 18

-Optimize comorbidities
-Be aware of increased incidence of OSA → Bring CPAP if pt uses one
-STOP BANG (if >3 highly suggestive of OSA)
-BMI cut off used to be 35-40. Now surgeries w BMI 44, some 50 BMI
-Remember neck circumference, airway assessment, positioning

Question 19

What are the special considerations for pediatric patients/former premature infants receiving outpatient/ambulatory anesthesia?

Answer 19

-Past URI within 6 weeks more likely to have some kind of airflow obstruction
-Premie under 60 weeks post gestational age should not be done due to Apnea risk: immature brainstem, periodic breathing, apnea up to 12 hours post op and due to Anemia associated apnea, Immature temp control, Immature gag reflex
-SIDS- siblings 4-5x more likely to die of SIDS
-Must have airway equipment available that is appropriate for the child

Question 20

What are the goals for outpatient anesthesia?

Answer 20

-Minimize physiologic changes associated with anesthesia
-Provide a fast/smooth onset of anesthetic action
-Promote intraoperative amnesia/analgesia
-Afford suitable operating circumstances
-Minimize perioperative anesthetic side effects
-Allow rapid offset of anesthetic influence while maintaining patient comfort

Question 21

What do you need to consider when choosing your anesthetic?

Answer 21

Surgical requirements, Skill of anesthesia provider, Patient choice, Patient age, ASA status, Level of care available post discharge, Risk of PONV, Post op analgesia requirements

Question 22

What are advantages associated with the use of Regional Anesthesia?

Answer 22

-Improve pain scores
-Decreases opiate use
-lowers the incidence of PONV
-Shortens the recovery period
-Reduces PACU stay
-Reduces unanticipated hospital admission
-Minimized side effects from general anesthesia
-Patients discharged home in less time w higher satisfaction

Question 23

What are disadvantages associated with Regional Anesthesia?

Answer 23

-Requires cooperation of both patient & surgeon
-May require more time initially
-Inherent problems associated w RA (sympathetic block, nerve injury, pneumothorax, fall risk, respiratory compromise)
-Time to discharge may be delayed for slow recovery of neuraxial block
-Additional education needed if patient to be sent home after single shot or continuous catheter peripheral nerve block

Question 24

What are the anesthetic techniques/procedures for outpatient plastic surgery?

Answer 24

Surgical duration <6 hrs
-Compression stockings on before induction
-<ASA3
-Females of menstrual age need blood hcg
-Foley placed if surgery >4hrs

Question 25

What airways are used in outpatient plastic surgery?

Answer 25

Local/MAC/GETA, Oral RAE

Question 26

How do you mitigate risk of fire in outpatient plastics?

Answer 26

Must communicate w surgeon
-Ex: when to turn O2 below 30%

Question 27

What is the management for Local Anesthetic Toxicity (LAST)?

Answer 27

-usually d/t accidental intravascular injection
-Airway mgmt, seizure suppression (prefer benzos, avoid propofol in those w CV instability)
-ACLS, avoid vasopressin, CCB, BB, or LA, Reduce epi doses to <1 mcg/kg
-Increased risk with extremes of age & hepatic dysfunction
-Cardiac toxicity likely caused by electrophysiological & cardiac dysfunction

Question 28

What are the treatment options for LAST?

Answer 28

Tx is supportive care, intralipid 20%
-Lipid Emulsion therapy: Bolus 1.5 mL/kg IV over 1 min & then continuous infusion

Question 29

What are the early S/Sx of LAST?

Answer 29

perioral numbness, tinnitus, agitation, confusion

Question 30

What are the late S/Sx of LAST?

Answer 30

CNS depression, seizures, coma, complete CV collapse

Question 31

What is the most cardiotoxic local anesthetic?

Answer 31

Bupivacaine

Question 32

What are the anesthesia considerations for dental anesthesia?

Answer 32

-State dental boards requirements for dentists to hold sedation permits may limit type of drugs that may be administered by a CRNA
-Shared airway: irrigation, blood, small instruments, filling materials may be aspirated
-CRNA must have access to the airway…suctioning by dental assistant is vital to prevent fluids going to back of throat —CRNA must be ready to step in to suction
-Throat packs must be changed before saturated; may cause choking & laryngospasm
-Trigeminal nerve pain may require more sedation; obesity/OSA may need nasal airway
-Antisialagogue may be necessary (glycopyrrolate)
-No waterboarding! Collaboration/Communication is key!
-HOB >30 degrees
-Must do our pre op assessment; dentist/surgeon is not doing it for us
-Space is at a premium
-A minimum backup of 2 functional E size cylinder O2 tanks must be available

Question 33

What are the criteria for discharging the patient from an ambulatory center to home?

Answer 33

Vital signs stable, Patient oriented, No resp distress, Swallow/cough reflexes intact, Minimal bleeding, Pain minimal/controlled, N/V minimal, Caregiver available

Question 34

What is the Aldrete Score that indicates the patient is ready for Phase 2 Recovery (ready to be home)?

Answer 34

> /= 9

Question 35

How is the Aldrete Score determined?

Answer 35

Activity, Respiration, Circulation, Consciousness, and Oxygenation

Question 36

How is the Activity Score calculated (Aldrete)?

Answer 36

Able to move four extremities voluntarily or on command (2)
Able to move two extremities voluntarily or on command (1)
Unable to move extremities voluntarily or on command (0)

Question 37

How is the Respiration Score calculated (Aldrete)?

Answer 37

Able to breathe deeply and cough freely (2)
Dyspnea or limited breathing (1)
Apneic (0)

Question 38

How is the Circulation Score calculated (Aldrete)?

Answer 38

BP +/- 20% of preanesthetic level (2)
BP +/- 20-49% of preanesthetic level (1)
BP +/- 50% of preanesthetic level (0)

Question 39

How is the Consciousness Score calculated (Aldrete)?

Answer 39

Fully awake (2)
Arousable on calling (1)
Not responding (0)

Question 40

How is the Oxygenation Score calculated (Aldrete)?

Answer 40

Able to maintain saturation >92% on RA (2)
Needs O2 to maintain saturation >90% (1)
Saturation <90% even with oxygen (0)

Question 41

How does morbidity and mortality in an office-based setting compare with morbidity and mortality in an ambulatory care setting?

Answer 41

-Claims arising from NORA locations have been shown to have a higher proportion of death (& severe injury) compared with those from the operating rooms
-Primarily caused by an adverse respiratory event d/t oversedation
-Most judged to be preventable by better monitoring techniques
-Majority of claims occur in GI endoscopy suite

Question 42

What are the 4 broad causes of injury in office-based practice?

Answer 42

Airway, respiratory, CV, med errors (from Justin flashcards)

Question 43

How can these 4 broad causes of injury in office-based practice be prevented?

Answer 43

Prevent with better monitoring, better protocols, certifications of staff (ex ACLS), better documentation and administration of medications, vigilance

Question 44

What emergency equipment must be present in the office-based setting?

Answer 44

Ambu bag, Back-up power, Defibrillator & crash cart available, Emergency medications, Oxygen analyzer is on, Emergency airways available, Suction source, Minimum of 2 O2 sources