Mod11: Office-Based Anesthesia

Question 1

_{Office-Based Anesthesia}

What is Office-Based Anesthesia (OBA)?

Answer 1

Anesthesia that is performed in a location, usually an office or procedure room, that is not accredited or regulated by a state agency as an ambulatory surgery center, and may have no accreditation at all

Question 2

_{Office-Based Anesthesia}

Who is doing office-based procedures?

Answer 2

Plastics - Dental - Ortho/podiatry

GI endoscopy - GYN/GU

Ophthalmology/Otolaryngology

Question 3

_{Office-Based Anesthesia}

In 2005 (13 years ago), what percentage of outpatient procedures were office-based?

Answer 3

24%

Question 4

_{Office-Based Anesthesia}

What are advantages of Office-Based Anesthesia?

Answer 4

Cost containment (facility fee)

Ease of scheduling (avoids multiple layers of scheduling)

Convenient for both patient & surgeon

Decrease exposure to nosocomial infections

Improved patient privacy

Continuity of care

Question 5

_{Office-Based Anesthesia}

Disadvantages of Office-Based Anesthesia mainly relate to issues addressing patient safety & peer review. What are some of those issues?

Answer 5

Absence of regulations regarding certification of surgeon or anesthesia provider

Surgeon/anesthesia provider performing procedures for which they have little or no training

Should be a system in place for monitoring CME, PEER reviews, performance improvement (Quality Assurance Committee)

May be absence of documentation, policies, & procedures, and of reporting adverse outcomes

Question 6

_{Office-Based Anesthesia}

True or False: GA is a state that does not regulate office-based surgery

Answer 6

True

Question 7

_{Office-Based Anesthesia - Office Safety}

What are the various causes of injury & death?

Answer 7

Obsolete and/or malfunctioning anesthesia machines

^{Not serviced routinely - Alarms malfunction}

Inadequate monitoring

^{Lack of pulse oximetry most common}

Inadequate resuscitation equipment

Inadequate pre- or postoperative evaluation

^{Pts not optimized to be done in an office}

Local anesthesia toxicity (plastics)

Human error*

Use of reversal drugs with short-half lives

Question 8

_{Office-Based Anesthesia - Office Safety}

What is the most common monitoring deficiciency in office setting?

Answer 8

Lack of pulse oximetry

Question 9

_{Office-Based Anesthesia - Office Safety}

What is a common safety concern in plastic centers?

Answer 9

Local anesthesia toxicity

Question 10

_{Office-Based Anesthesia - Office Safety}

What is the biggest cause of injury and death?

Answer 10

“Human error”

Question 11

_{Office-Based Anesthesia - Office Safety}

What safety concern is associated with the Use of reversal drugs with short-half lives

Answer 11

Resedation after the reversal wares of

Question 12

_{Office-Based Anesthesia - Office Safety}

Which specific human errors are a major safety concern?

Answer 12

Slow recognition/response to an event

^{Hyoxemia - Hypovolemia - Occult blood loss during lengthy procedure}

Lack of experience

Drug overdosage (most commonly local anesthetics)

Question 13

_{Office-Based Anesthesia - Office Safety}

What’s the most common drug overdose in Office-Based Anesthesia

Answer 13

Local anesthetics

Question 14

_{Office-Based Anesthesia - Patient Selection}

Why must patients be “medically optimized”

Answer 14

Because of the risks associated with OBA

Question 15

_{Office-Based Anesthesia - Patient Selection}

When should a Preoperative evaluation be completed prior to office-based procedure? What should it include?

Answer 15

Within 30days

_{Should include:}

History & physical examination

Pertinent labs obtained

Medically indicated consults completed

Question 16

_{Office-Based Anesthesia - Patient Selection}

Why must ANESTHETIC COMPLICATIONS BE AVOIDED?

Answer 16

Office location is often remote

Anesthesia provider may be unable to get assistance should it be required

Question 17

_{Office-Based Anesthesia - Patient Selection}

Which patients are poor candidates for Office-Based Anesthesia?

Answer 17

Poorly controlled DM

Anticipated significant blood loss

Significant postoperative pain

History of substance abuse

Seizure disorder

MH susceptibility

Potential difficult airway (Mallampati IV)

^{Morbidly obese/OSA: Unable ventilate - Sensitive to respiratory depressant effects of sedatives/analgesics}

NPO < 8hrs

Significant drug allergies

Risk for pulmonary aspiration

Question 18

_{Office-Based Anesthesia - Patient Selection}

What ASA score is ideal candidates for Office-Based Anesthesia?

Answer 18

ASA 1 or 2

Question 19

_{Office-Based Anesthesia - Office Selection}

Which type of anesthetic technique must the ideal office setting be appropriately equipped and stocked to perform?

Answer 19

General Anesthesia

Question 20

_{Office-Based Anesthesia - Office Selection}

Which Airway supplies must be available?

Answer 20

Nasal cannulas - Oral/nasal airways - Face masks

Self-inflating bag-mask ventilation devices (Ambu)

Laryngoscopes (multiple sizes & styles)

Various sizes tracheal tubes

Intubating stylettes

Question 21

_{Office-Based Anesthesia - Office Selection}

Which Emergency/difficult airway equipment (ASA Difficult Airway Algorithm) equipments must be available?

Answer 21

LMA’s

Cricothyroidotomy kit

Means for transtracheal jet ventilation

Question 22

_{Office-Based Anesthesia - Office Selection}

What do you have along with your Anesthetic drugs, which would allow you to administer IV drugs?

Answer 22

Vascular cannulation equipment

Question 23

_{Office-Based Anesthesia - Office Selection}

Which Emergency drugs must you have available?

Answer 23

ACLS

Dantrolene & MH supplies

Question 24

_{Office-Based Anesthesia - Office Selection}

Which drugs must you have available if you suspect a potential for an MH crisis?

Answer 24

Minimum 12 bottles of Dantrolene (per MHAUS)

Must be prepared to begin the initial treatment

Question 25

_{Office-Based Anesthesia - Office Selection} What are Perioperative monitoring standards for Office-Based Anesthesia?

Answer 25

NI**BP** ^{(with assortment of cuff sizes)} **Heart rate**/**EKG** **Pulse oximetry** **Temperature** *Perioperative monitoring must adhere to the ASA &/or AANA Standards for Basic Anesthetic Monitoring*

Question 26

_{Office-Based Anesthesia - Emergencies} What should you have in place if a complication or Emergency occurs?

Answer 26

Establishment of a _written plan for emergency transport_ of the patient to a _comprehensive care center_ if a complication occurs

Question 27

_{Office-Based Anesthesia - Emergencies} Which Emergencies must you have contingency plans for?

Answer 27

Bomb threat Power loss/electrical failure Equipment malfunction Loss of O2 supply pressure Cardiac/respiratory arrest Natural disaster (fire/earthquake/hurricane) **MH** - Massive blood loss

Question 28

_{Office-Based Anesthesia - Procedure Selection} What should the maximum lenght for an Office-Based procedure be?

Answer 28

**6hrs**

Question 29

_{Office-Based Anesthesia - Procedure Selection} When should and Office-Based procedure be completed?

Answer 29

By 3pm ^{Must be completed ideally when there is still staff in the office}

Question 30

_{Office-Based Anesthesia - Procedure Selection} Which potential intraop complications are contraindications for Office-Based procedure?

Answer 30

**Hypothermia** Anticipated **blood loss** Significant f**luid shifts**

Question 31

_{Common Office-Based Procedures} Which anesthetic techniques are appropriate for Office-Based Ophthalmology/otolaryngology procedures?

Answer 31

Topical anesthesia Periorbital/retrobulbar block frequently used Supplemental sedation may be required

Question 32

_{Common Office-Based Procedures} What's the minimum age requirements for a child to undergo OBA?

Answer 32

**No minimum age** requirements for a child to undergo OBA is established

Question 33

_{Common Office-Based Procedures} Although there is No established minimum age requirements for a child to undergo OBA, what age should reasonable candidates be? with what ASA score?

Answer 33

**\> 6mos** ASA 1 or 2

Question 34

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Why should you use anesthetic agents and techniques that allow the patient to be ready for discharge home soon after the completion of the procedure?

Answer 34

Maximize alertness & mobility Minimize risks for the need for a prolonged PACU stay ^{(PONV - Pain)}

Question 35

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} True or False: Any type of anesthesia may be used in the office setting.

Answer 35

**True** MAC → Regional → General Continuum, impossible to predict how patient will react

Question 36

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} What is the most commonly used anesthetic technique?

Answer 36

**MAC sedation** (IV)

Question 37

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} What are the beneficial characteristics of drugs used during MAC (IV sedation)?

Answer 37

Short **half-lives** **Inexpensive** **Void** of _undesirable side effects_ (PONV)

Question 38

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} What are the most commonly used drugs for MAC (IV sedation)?

Answer 38

Midazolam - Fentanyl - Propofol - Meperidine

Question 39

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which Ultra-short acting analgesic used for MAC (IV sedation) increases the risk of PONV?

Answer 39

**Remifentanil**

Question 40

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which drug could be used for Anesthesia & analgesia Does not depress respirations is Not associated with N/V is inexpensive is a/w Hallucinations/secretions\*?

Answer 40

**Ketamine**

Question 41

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which drug decreases propofol requirements and can be used fo BP control during MAC (IV sedation)?

Answer 41

**Clonidine**

Question 42

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} True or False: MAC anesthesia is safer than GA in Office-Based Anesthesia

Answer 42

False This is a False impression

Question 43

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} True or False: General Anesthesia _cannot_ be administered safely in the office setting

Answer 43

False General Anesthesia can be administered safely in the office setting

Question 44

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} What are advantages of GA in office settings?

Answer 44

**Decreases** risk of _intraoperative airway obstruction_ Pt movement does not distract surgeon _Eliminates_ “**seesaw effect**” of IV sedation ^{(especially if doing boluses over infusion)}

Question 45

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which airway device could be used for "Light general anesthesia"?

Answer 45

**Mask** (TIVA + O2 mask, or Regular O2 mask w/ circuit strapped to the pt's face **LMA** (volatile agents through LMA, Typically Sevo: less irritating along with N2O)

Question 46

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which airway device is used to deliver Desflurane & Sevoflurane (N20)?

Answer 46

**ET Tube**

Question 47

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Which drug is used to deliver TIVA?

Answer 47

Propofol

Question 48

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} What's "Room Air General"?

Answer 48

Oxygen mask Propofol (large dose) + Remifentanil

Question 49

_{Office-Based Anesthesia - Anesthetic Agents &Techniques} Why is the use of BIS monitoring a/w decrease time to extubation & discharge readiness during MAC?

Answer 49

It leads to a Decrease total propofol usage during MAC

Question 50

_{Office-Based Anesthesia - PACU} True or False: since Office-Based setttings often lack a Formal PACU, ASA/AANA standards for monitoring and documentation throughout the postoperative period may not be adhered to.

Answer 50

False ASA/AANA standards for monitoring and documentation throughout the postoperative period **must be adhered to** regardless

Question 51

_{Office-Based Anesthesia - PACU} In the absence of a recovery nurse, who should recover the patient?

Answer 51

Anesthesia Staffing in recovery area must be adequate

Question 52

_{Office-Based Anesthesia - PACU} Which monitoring is imperative in the PACU?

Answer 52

Pulse oximeter

Question 53

_{Office-Based Anesthesia} True of False: Office-Based Anesthesia is slowing down

Answer 53

**False** OBA rapidly expanding and poses unique challenges to the anesthesia provider

Question 54

_{Office-Based Anesthesia} True or False: Regulation of office-based surgery have kept pace with the growth of OBA

Answer 54

False Regulation of office-based surgery _have not_ kept pace with the growth of OBA

Question 55

_{Office-Based Anesthesia} What's the main responsibility of the anesthesia provider in OBA?

Answer 55

To ensure every possible **safety** measure is afforded to their _patients_

Question 56

_{Office-Based Anesthesia} Important websites

Answer 56

AANA Standards for Office Based Anesthesia.pdf ASA Office Based Anesthesia Guidelines.pdf