Week 4 - ASC Orientation

Question 1

What are patient and family expectations for outpatient surgery?

Answer 1

• Safety during procedure
• Relief of pain
• Freedom from nausea
• Rapid return to normal daily routine
• Minimal burden to pt caretakers, which may include family or friends

Question 2

How is outpatient anesthesia different?

Answer 2

Respects surgeon’s and patient’s time as valuable

Maximizes predictability through preparedness and prevention

Multidisciplinary approach required

Patient centered (patient’s are driving the change)

Question 3

What are the goals of outpatient anesthesia?

Answer 3

• maintain a predictable environment through critical case and procedure selectivity
• promote a culture of vigilance and patient safety that exceeds that of the hospital setting
• monitor peer-reviewed literature and track patient outcomes and experience to develop evidence based “best practices”
• standardize workflow with “best practices” that leverages predictability to create consistently excellent outcomes for patients, family and surgeons

Question 4

What are the phases a ambulatory surgical patient goes through from start to finish?

Answer 4

Evaluation: selection and screening

Preop Prep and Assessment: confirmation phone call, day of surgery nurse intake, anesthesia preop assessment

Intraop

Postop: immediate recovery phase 1, immediate recovery phase 2, continued observation, post-discharge, postop visit, continued recovery

Question 5

What are the goals of the ASC team during the evaluation phase?

Answer 5

Maximize predictability through preparedness and selectivity

Question 6

What are the goals of the ASC team during the preop prep and assessment phase?

Answer 6

Initiate multimodal PONV and pain management

Reaffirm optimal risk reduction

Question 7

What are the goals of the ASC team during the intraop phase?

Answer 7

Deliver minimally invasive anesthesia

Question 8

What are the goals of the ASC team during the postop recovery phase?

Answer 8

Continue multimodal PONV and pain management

Enable timely discharge

Conduct criteria driven recovery assessment

Deliver effective pt and caregiver education

Question 9

What are the goals of the ASC team during the postop post discharge phase?

Answer 9

Prevent unanticipated admission or acute care visits

Maintain around the clock patient access to clinical advice

Support caregiver

Track outcomes and patient experience through diligent follow up

Question 10

What is completed during the days to weeks preop phase?

Answer 10

• Assess social support (escort/caregiver)
• Evaluation and testing (pt screening and further workup – NO routine testing, just targeted)
• CV risk assessment (4 met rule – must have met 4 to be done in ASC)
• Assess for undiagnosed OSA (STOP-BANG)
• Assess DM (need A1C <7)
• Chronic Pain patients need plan for post op (consult pain clinic)

Question 11

What is completed during the day of surgery preop phase?

Answer 11

• Acute pulmonary conditions: symptomatic and optimized (wheezing at rest, unable to climb 1 FOS –> cancel) — recent URI delay procedure 4 weeks
• Difficult airway: have plan and backup plan
• Hypertension: no set number for proceeding – new onset arrhythmia, angina, uncompensated HF –> cancel
• Pregnancy testing: some do all, others do some
• Preop medications: premedication for postop pain and PONV

Question 12

What are the pros and cons of using inhalational general anesthesia in the ASC?

Answer 12

PROS:

• Neuromuscular blockade and intraperitoneal procedures
• Maximal intraop airway control when preformed with intubation

CONS:

• PONV/PDNV
• Airway injury
• Cognitive dysfunction
• Delayed discharge
• Hyperalgesia
• SUX induced myalgia
• Residual neuromuscular blockade

Question 13

What are the pros and cons of using IV general anesthesia in the ASC?

Answer 13

PROS:

• Less PONV with Propofol
• Neuromuscular blockade and intraperitoneal procedures
• Maximal intraop airway control w/ intubation

CONS:

• Airway injury
• Cognitive dysfunction
• Delayed discharge
• Hyperalgesia
• SUX induced myalgia
• Residual neuromuscular blockade

Question 14

What are the pros and cons of using regional anesthesia in the ASC?

Answer 14

PROS:

• Prolonged postop analgesia
• Less PONV
• Less risk of airway injury
• Rapid recovery
• Reduced exposure to anesthesia

CONS:

• LA systemic toxicity
• Peripheral nerve injury
• Spinal headache w/ neuraxial blockade
• Equipment costs
• Specialized training
• Recall of operation and the associated stress

Question 15

What are the pros and cons of using MAC anesthesia in the ASC?

Answer 15

PROS:

• Less exposure to anesthetic doses
• Rapid recovery
• Less PONV/PDNV
• Los incidence of sore throat

CONS:

• Minimal airway control
• Patient dissatisfaction from unexpected recall
• Over sedation
• OR fires with an open system
• Hypercarbia, hypoxemia

Question 16

What are the five general principles for improving patient outcomes and experience in the ASC?

Answer 16

1. thorough preop eval, pt and case selection, anesthesia delivery decisions, and postop recovery room care are required to provide optimal pt outcomes
2. without opioids and with minimal multimodal analgesia, postop pain and nausea decrease, cognitive function is preserved, and pt satisfaction is high
3. when possible choose only regional anesthesia or a combo regional/general to improve pt satisfaction
4. use evidenced based, preemptive antiemetic therapy for most pts given a general anesthetic
5. favor TIVA over inhaled anesthetics for general to improve pt outcomes

Question 17

What is included in the postop phase in the ASC?

Answer 17

Beginning of Recovery –> see if you can fast track the pt (must score 12/14 with no score less than 1 in any category)
-multimodal analgesia, PONV

Discharge –> adequate assessment and instructions

Post-discharge –> evaluated for nausea and pain

Question 18

What are the risk factors for PONV?

Answer 18

Female
Risk surgery/Surgery type
Volatile anesthesia
Hx of PONV or motion sickness
Non-smoking
Duration (hour)
Age <50
Postop opioid

*listed to greatest risk factor to least

Question 19

What is the optimal multimodal analgesia in the ASC?

Answer 19

1st: Regional Anesthesia, Acetaminophen, and NSAIDS
2nd: Lidocaine and Magnesium
3rd: Ketamine and Dexmedetomidine
4th: Opioids
* avoid medications that work on the brain – causes sedation thus delaying discharge

Question 20

What is included in the post-discharge phase in the ASC?

Answer 20

Assessment of PDNV –> send home with antiemetic prescription

Assessment of Pain

Assessment of nerve injuries

Multidisciplinary team –> phone calls, triage line

Question 21

What does the Modified Aldrete PACU discharge score assess?

Answer 21

Determines patient’s readiness to be discharged from PACU or able to bypass PACU:

• level of consciousness
• physical activity
• hemodynamic stability
• respiratory stability
• oxygen saturation status
• postop pain
• postop emetic symptoms

**minimal score of 12 (w/ no score <1 in any category) and patient may bypass PACU after general or regional anesthesia