Ambulatory and Laparoscopic Surgery Flashcards
(72 cards)
1
Q
What is the difference between ambulatory surgery, same day surgery, and outpatient surgery?
A
Nothing! They are all terms for the same thing.
2
Q
__% of all elective surgeries are performed as outpatient surgeries
A
70%
3
Q
Why are more surgeries able to be performed on an outpatient basis?
A
- Anesthesia wise, shorter acting drugs have been developed
- Advances in surgical technique that are less invasive
4
Q
What are some benefits of ambulatory surgery?
A
- Increased patient satisfaction
- More efficient
- Decreased cognitive dysfunction in the elderly
- Decreased post-op infection rates (better for immunocompromised patients)
- Decreased pulmonary complications (PE and pneumonia)
- Decreased cost (minimally invasive surgeries have decreased cost up to 50%)
5
Q
Why is ambulatory surgery good for children and the elderly?
A
It offers less stress and less interruption in their daily schedules
6
Q
Why is ambulatory surgery more efficient than general surgery
A
- Lack of dependence on availability of hospital beds
- Greater flexibility in scheduling operations
- Higher volume of patients results decreased surgical wait times (don’t need to wait for weeks in order to have your surgery)
7
Q
Are ambulatory surgery patients usually healthy?
A
- Not necessarily.
- Even some ASA 3 and 4s are having ambulatory surgery.
8
Q
The four design schemes for outpatient surgeries
A
-
Hospital Integrated:
- Ambulatory surgical patients are managed in the same surgery facility as inpatients.
- Outpatients may have separate preoperative preparation and second-stage recovery areas [vast majority of cases that are done in hospitals like GUH and WHC]
-
Hospital Based:
- A seperate ambulatory surgical facility within a hospital handles ONLY outpatients.
-
Freestanding:
- These surgical and diagnostic facilities may be associated with hospitals but are housed in separate buildings that share no space or patient care functions.
- Preoperative evaluation, surgical care, and recover occur within this unit.
-
Office based:
- These operating or diagnostic suites (or both) are managed in conjunction with physicians’ offices for the convenience of patients and health care providers.
- Safe recovery of patients can be an issue here due to lack of a PACU.
9
Q
Who sets the standards for quality of care in outpatient centers?
A
- Governmental Licensing
- Accreditation bodies
- (AAAHC, JCAHO) Accreditation is required for medicaid/medicare reimbursement
- Professional organizations
- (AANA, ASA) Know the AANA standards for office based anesthesia practice for the exam!!****
10
Q
Surgical procedures suitable for ambulatory surgery should be accompanied by:
A
- Minimal postoperative physiologic disturbances and an uncomplicated recovery.
- Potential for blood loss, pain , PONV, all important.
- Patients undergoing procedures that are likely to be associated with postoperative surgical complications or major fluid shifts should be admitted to the hospital overnight.
11
Q
Does obesity alone increase risk associated with ambulatory surgery?
A
- No.
- Morbid obesity [BMI > 35] alone not a sole contraindication to outpatient surgery,
- exception being adding other co-morbidities such as HTN, CAD, ASTHMA, and COPD = DO HAVE a higher incidence of postop morbidity with SDS.
12
Q
Procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited to a
A
23-hour stay
13
Q
Procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited to a
A
23-hour stay
14
Q
Elderly patients are at more risk for ____, but less risk for ___ & ____
A
More CV events
Less pain and PONV
15
Q
Can those susceptible to MH have outpatient surgery?
A
Yes, as long as a non-triggering technique is used and the family is educated to monitor for s/s of MH
16
Q
Is OSA alone associated with increased risk of hospital admission?
A
No.
17
Q
SDS recommendations for those with OSA
A
- OK to have if superficial surgery or minor ortho w/local or regional, lithotripsy
- “Equivocal” to have if Superficial surgery with GA, tonsillectomy for those >3 yr old, gynecologic laparoscopic
- Avoid SDS if it is airway surgery, tonsillectomy for those s a small surgery, those with OSA are fine to go home.
18
Q
Factors that will increase the risk of post-op hospital admission following SDS
A
- > 65 years
- OR time >120 minutes (results in more PONV)
- CV diagnosis (CAD, PVD, etc.)
- Malignancy
- HIV
- Regional and general anesthesia
19
Q
In a free-standing facility, the CRNA or MDA cannot leave the facility until when?
A
Until the last patient has been discharged.
20
Q
Can alcoholics have SDS?
A
No. They often have too many other comorbidities.
21
Q
Fasting guidelines for healthy patients
A
- fasting 2 hours for clear liquids
- 4 hours for breast milk
- 6 hours for non-human milk/formula
- 6 hours for a light solid meal
- 8 hours heavy meal
22
Q
Half life of clear fluids in the stomach
A
10-20 minutes
23
Q
Studies show up to 150ml of orange juice or coffee 2 hours before surgery had this effect on gastric volume and pH
A
- No effect.
- But remember, this is for healthy patients!
- The same rules wouldn’t really apply for those with DM or GERD.
24
Q
Why is patient education before surgery important?
A
- So that the patients know what to expect.
- Educated patients tend to have less anxiety, pain and post-op complications.
- This should occur as early as possible before the patient goes to the OR (1-2 weeks if possible).
25
What is the main purpose of the pre-op examination?
To identify patients who have concurrent medical problems requiring further diagnostic evaluation of active treatment before surgery.
26
People who are **highly anxious** are at higher risk for this post-op.
**Nausea** and **vomiting**.
27
What should determine the types of **testing** that a patient needs before surgery?
Their **physical exam** and **medical history**.
28
Surgery should be postponed after an URI for ___ weeks.
1. **6 weeks.** Airflow obstruction has been shown to persist for 6 wks post URI.
2. However, if a patient with a URI has a normal appetite, does not have a fever or elevated RR and does not appear toxic it is probably safe to proceed with the planned procedure.
3. Really, it seems like you just need to use your clinical judgement.
29
Use of **benzos** in SDS
1. Can reduce **anxiety, pain**, and **PONV,** But use clinical judgement
* Can cause cause significant **amnesia**, which isn't the greatest if the person is gonna go home.
* Aim towards lower doses of versed (**1-2**mg)
30
Use of opioids in SDS
* compare risk of **post-op pain with PONV.**
* If minimal pain is expected or surgeon is very good about injecting local, etc., then use lower doses of opioids.
* Remember that most people would rather have pain than be nauseous.
31
These procedures are **highly associated with PONV**
1. Laparoscopy
2. lithotripsy
3. major breast surgery
4. ENT
32
Risk factors for PONV
1. Type of surgery
* especially Laparoscopy, lithotripsy, major breast surgery, ENT
2. Types of anesthetics being given
3. Individual patient risk factors
* (hx of PONV and motion sickness, anxiety, non-smoker, within 1 wk of menstrual cycle, age)
33
Medications that be used to prevent PONV
1. **Droperidol:** low dose (0.625 mg)
* association with QT prolongation though!!
* Give lowest possible dose after induction.
2. **Dexamethasone** (4-8mg)
3. 5-HT Antagonists
* Ondansetron (2-4mg)
4. Dolasetron (12.5mg)
5. Phenergan (6.25mg – 12.5mg)
6. Metoclopramide (10-20mg)
7. Antihistamines (dimenhydrinate)
* works on CRTZ and vestibular pathways.
* Helpful in motion induced emesis and those undergoing middle ear and stabismus surgery.
8. Neurokinin- 1 (NK-1) antagonists (aprepitant) very new.
* Synergistic with zofran and may be even better than propofol. In trials and expensive.
9. Propofol use
10. Scopolamine patch
* (anticholinergic associated with SE such as dry mouth, lethargy, HA, Hydration
11. Adequate hydration will minimize nausea and other side effects (dizziness, drowsiness, thirst)
34
What is special about **propofol** and **midazolam** related to their anti-emetic effects?
Their anti-emetic effects **outlast** their sedative effects
35
What is the most cost effective pairing of medications for PONV prophylaxis
**Droperidol** (**0.5-1**mg)
and
**decadron** (**4-8**mg)
36
Outpatients with the highest risk of **PONV** will benefit from
**5HT antagonists** (Zofran)
37
Why is hydration good at preventing PONV?
**Hypotension** and **hypovolemia** are huge **triggers** for PONV
38
SeaBand and ReliefBand provide accupressure to this acupoint
* **P6**, bitches!
* 2FB proximal to the crease of the wrist
39
Pain control for outpatient surgery
1. Opioids, be careful d/t resp depression and PONV
2. Neuraxial --\> but may cause residual motor block or SNS block and can cayse delays in discharge
3. PNB with MAC popular for surgery
4. Pts can be sent home with perineural catheters.
5. Stay in place for about 4 days.
6. Pt and family must be educated on how to use the pump and s/s of LA toxicity
40
If neuraxial technique is used for outpatient sx, what LAs are preferable?
**Lidocaine** and **procaine** d/t shorter DOA
41
Can a patient be discharged even if an extremity of theirs is still numb?
Yes, it's usually **placed in a sling** and the patient is warned about their increased risk of injury until sensation returns
42
What types of cases may precedex be good for?
1. **Carotid endarterectomy** or neuro cases where you want a **smooth wakeup.**
2. You have risk for **brady** and **hypoTN**, but may be worth the risk for a smooth wakeup.
43
Incidence of sore throat with ETT vs. LMA
**45%** vs **18%**
44
Thermoregulation is a big issue in this type of outpatient surgery
**Plastic surgery.**
1. Often have multiple things going on at once (tummy tuck, boob stuff, etc).
2. Enhances 3rd space losses and decreases space left to place a bair hugger.
3. Also these cases can be lengthy.
45
Criteria for being able to **fast-track** a patient
1. Awake and oriented
2. Able to **move extremities** on command and move into a chair
3. VS within **15%-20%** of normal
4. SaO2 **\>90%**
5. Able to breath deeply
6. No pain or nausea
46
Post-op, ambulatory surgical patients should be able to control pain with
PO pain meds
47
Discharge Criteria
1. Usually an institutional scoring system that looks at ability to tolerate liquids, void, walk, bleeding, VS stability, and control of pain and nausea.
2. Opioids may inhibit ability to void.
3. We want them converted to NSAIDs if possible.
48
What are the 3 most common reasons for delay in discharge?
1. Drowsiness
2. N/V
3. pain
49
What can't a patient do for **24 hours** after the procedure?
1. No driving
2. power tools / large machinery, or business decisions for 24 hours, even if only propofol was given.
50
Distention and stretching of visceral organs can lead to referred pain to
The **shoulders**.
This can be pretty intense pain.
51
Relative **contraindications** to **laparoscopic** procedures
1. **Increased ICP** (impairs venous return from the head)
2. **Hypovolemia** (d/t decreased venous return)
3. V/P **Shunt** or peritoneojugular shunt
* (OK if have unidirectional valve resistant to IAP)
4. Severe **CV disease**
* **(**d/t CV alterations that occur
* no **AS** or **CHF** patients should have laparoscopic
5. Severe **respiratory** disease
52
**Gases** that can be used for insufflation of the abdomen
**CO2**
Inert gases like **Argon** and **Helium**
53
Can gasless laparoscopic procedures be performed?
* Yes, for those who couldn't handle insufflation (hemodynamically unstable patients).
* But, makes it very difficult for the surgeon.
54
Why is CO2 the gas of choice for insufflation?
1. More **soluble** in blood than air, N2O, O2, or He
2. **Non-flammable**
3. Rapid **elimination** from the body
* CO2 embolus would therefore be better tolerated than a Helium embolus.
* The body is used to handling and processing CO2
55
IAP should be less than \_\_\_\_\_mmHg after insufflation
**15 mmHg**
56
If the abdomen is insufflated, and you can't get your peak pressures down and you have poor cardiac output, what might you do?
Ask the surgeon to **back off** on his insufflation pressure.
57
Risks associated with laparoscopic procedures
1. Physiologic changes d/t pneumoperitoneum and positions requires
2. Long case durations
3. Risk of unsuspected visceral injury
4. Difficult to evaluate the amount of blood loss
5. Aspiration risk (inset OG tube at beginning of the case!)
58
Reasons for increase in CO2 with insufflation
1. **Absorption** of CO2 from the peritoneal cavity
* Main Cause \*\*\*\*\*\*
2. Abdominal **distention**
* VQ mismatch, FRC ↓
* decreased pulmonary compliance
3. Patient **position** – VQ mismatch
4. **Volume-controlled mechanical ventilation** – VQ mismatch
5. **Depression of ventilation** by anesthetic agents if spontaneous breathing
6. **CO2** **emphysema** (SQ or body cavities)
7. Capnothorax
8. CO2 embolism
9. Selective bronchial intubation
59
**Hemodynamic** changes that occur with insufflation
1. Decreased CO **10-30%**
1. d/t decreased venous return
2. depends on CO2 insufflation, position
3. very bad in patients with a poor EF
2. Decreased **venous return**
3. Decreased **LVEDV**
4. Increased **intrathoracic** pressure
5. Increased **right atrial** and **PA** occlusion pressures
6. Minimal increase HR
7. Increased **aBP, PVR, SVR**
* (catecholamines, renin-angio, vasopressin)
8. Increase risk for **arrhythmias** (severe vagal response)
9. Activation of the **RAAS**
60
Hypercapnea is associated with
1. acidosis
2. decreased cardiac contractility
3. decreased threshold for arrhythmia
4. decreased SVR.
61
How much **time** does it take **after desufflation** for hemodynamics to return to normal?
**1 hour**
62
If neuraxial technique is used, this level must be blocked for laparoscopic surgery
**T4-5**.
This is risky though.
SNS blockade makes it more difficult to compensate for CV and pulmonary changes.
63
Can you use an LMA with laparoscopic procedure?
* Yes, but it's not a great idea.
* **Unable to prevent** aspiration, control ventilation, or give muscle relaxant.
* **1/3 of deaths** during lap surgery occurred during GA **without** an ETT
64
What should you do after every position change when getting ready for a laparoscopic surgery?
Recheck ETT position!
Listen to BS bilaterally.
65
Tilt of the patient shouldn't exceed \_\_-\_\_ degrees so that the patient doesn't fall out of the bed
**15-20** degrees
66
Benefits of placing an OG tube before laparoscopic surgery begins
Decreases risk of **aspiration**, and decreases **size of the stomach**, reducing the risk of **perforation** during trocar placement
67
What to do if lap procedure is converted to open?
1. Place the patient **supine**
2. Consider a new **fluid plan**
1. (will have more 3rd space losses)
3. Consider new **pain plan** (more pain)
4. Need to **alter your vent** settings to something more traditional.
68
S/S and treatment of **CO2** embolism
1. Tachycardia, arrhythmias, hypotension, increased CVP, millwheel murmur (heard by esophageal stethoscopes), hypoxia/cyanosis.
2. **Doppler** and **ETCO2** most **sensitive** for detection of embolism.
3. Would see a **sudden drop** in ETCO2 waveform.
4. Routine CVP not indicated but may want to place a CVP for rescue (aspiration of air) if a CO2 embolus occurs.
5. **Treatment** = immediate release of pneumoperitoneum, steep trendelenberg, left lateral position, discontinue N2O, 100% FiO2, Hyperventilate, CPR – chest compression breaks up into air bubbles. Consider CPB.
69
Is SQ emphysema a contraindication for extubation?
No.
70
What to do if you start noticing SQ emphysema?
* Ask the surgeon to **desufflate**.
* Increase **MV** to blow off CO2,
* then re-insufflate at a **lower pressure.**
71
PONV and lap procedures
* **40-75%** of patients have PONV with lap procedures
* **Propofol** decreases PONV
* Remember to **decompress** the stomach
* Give **anti-emetics**
* **Opioids** will increase incidence
* Give **zofran** and **decadron** together
72
To help reduce incisional pain, ask surgeon if
1. they plan on using local.
2. Usually the attending leaves for closure and the resident may forget to give local.
3. This is a subtle way to remind them. **We're so sneaky.**
