Outpatient Surgery Flashcards by lindsey france

OP surgery centers are: (examples)

Ambulatory Surgical centers (ASC), Office based (OBA), stand alone, Hospital OP

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OP Anesthesia criteria guidelines

Vary from Facility to facility

- should be agreed upon by surgeon, anesthesia & staff

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OP Anesthesia criteria for types of patient

depend on affiliation (hospital) or free standing facility (ex - cardiac pts, co-morbidities, peds)
proximity of office/ASC to a TERTIARY care facility
Community rescources (type of hospital and ASC or OBA)

Ultimately up to you, CRNA/surgeon to determine type of pt you accept

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ASC safer record than ____

OBA

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An OBA or ASC must have all items required to follow:

ASA guideline on the mgmt of a difficult Airway

HOPD may not require this b/c of it’s location within higher level of care facility

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Center personnel and Anesthesia are often required to be:

ACLS/BLS/Pals certified b/c they will serve as the primary care giver for a longer period of time

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b/c of OP facility isolation of emergency events what should be provided to enhance staff readiness?

simulation exercises

**ensure they have Carts, airway tools, equipment, meds, etc.

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OP Anesthesia criteria on Taking Pt Hx:

some HX is important; may discover pt is not appropriate for OP Center.

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OP Anesthesia criteria for LABS

Not obtained if not necessary

- pregnancy test likely done on women of childbearing age; controversial

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Routine EKG:

>65 yrs
HX of HF
Previous MI/angina
high cholesterol
Significant valvular disease
family hx of sudden death

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Usually no need for lab testing except:

unstable chronic dx
potential high blood loss (a good reason NOT to do procedure in ASC/OBA)
expected use of contrast dye (BUN/crt)

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Overall; OK for Non-Hospital Environment IF:

-Cardiac Stable
- no entry into Spaces of:
T-thoracic
V-vascular
P-Peritoneal

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STOP Signs on Day of Surgery: CARDIAC

unstable angina
labile HTN
severe valvular disease
Cardiac Dysrhythmias
MI w/in 3 mos WITH CP or at risk myocardium
Drug eluting coronary stent placed w/in 1 YEAR
bare metal stent w/in 1 month

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Stent criteria NOT to do OP Surgery

Drug eluting coronary stent placed w/in 1 YEAR

- bare metal stent w/in 1 month

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Is smoking a stop reason for surgery?

no - we aren’t going to talk them into quitting

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STOP if 3 or More of the Following Cardiac RF’s:

ischemic Heart disease
hx of chf
insulin dept DM
CRD (CR>2.0 mg/dl)
TIA
CVA
AICD is facility dependent

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Creatinine level we need to know for potential surgical risk factors

> 2.0 mg/dl

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STOP Signs on Day of Surgery: PULMONARY

pt is wheezing after max sufficient therapy
symptomatic!
unable to climb flight of stairs w/o SOB
Pulmonary HTN
these may be more appropriate for Hospital OP surgery vs. free standing

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STOP Signs on Day of Surgery: RENAL

elevated CRT especially in those w/co-morbidities (CVA, etc.)
A/V fistulas (creation/revision)
Unstable Renal Failure
assoc w/High Morbidity rates and are not good candidates for free standing OP

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Invasive Pediatric Airway surgeries should be done where?

Hospital based OP surgery vs Free standing

-access to ped intensivists and RT

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Overall Goals of OP Surgery

convenience
low cost
care aligned w/pt and surgeon goals
safe
diminish/eliminate Pain, PONV, PostOP cognitive impairment

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Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

GENERAL ANESTHESIA

BENEFITS

NMB and intraperitoneal procedures
Max. intraop airway control when performed with intubation

ADVERSE EFFECTS

PONV/PDNV
airway injury
Cog. disfunction
delayed d/c
hyperalgesia
Succinylcholine induced myalgia
residual NMB

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Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

GENERAL INTRAVENOUS

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BENEFITS

Less PONV w/propofol
NMB and intraperitoneal procedures
Max. intraop airway control when performed with intubation

ADVERSE EFFECTS

airway injury
Cog. dysfunction
delayed d/c
hyperalgesia
Succinylcholine induced myalgia
residual NMB

Benefits and AE’s of Anesthesia Techniques (TBL 37.5)

REGIONAL

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BENEFITS

Prolonged postOp analgesia
less PONV
less risk of airway injury
rapid recovery
reduced exposure to anesthesia

ADVERSE EFFECTS

local anesthetic systemic toxicity
Peripheral nerve injury
spinal H/A with neuraxial blockade
equipment costs
specialized training
recall of operation and the associated stress

Benefits and AE's of Anesthesia Techniques (TBL 37.5) | MAC

BENEFITS - less exposure to anesthetic doses - rapid recovery - less PONV/PDNV - low incidence of sore throat ADVERSE EFFECTS - minimal airway control - pt dissatisfaction from unxpected recall - oversedation - operating room fires w/open system - hypercarbia/hypoxemia - pt discomfort

Comorbid Conditions associated w/OSA | TBL 37.4

``` HTN Arrhythmias Cor pulmonale Ischemic Heart disease DM CVA Daytime sleepiness Depression Decreased vitality and social funtioning on SF-36 (reduced quality of life) ```

Disease related potential complications associated w/OSA: | TBL 37.4

``` Difficult mask ventilation/ intubation O2 destauration and hypoxemia Exacerbation of cardiac comorbid conditions delayed extubation Risk of Reintubation Prolonged recovery room stay Hypoxic brain injury Death ```

Characteristics that may Increase OSA" | TBL 37.4

``` Down Syndrome NM disease CP hx of difficult intubation enlarged tongue or tonsil size ```

STOP BANG | and scoring

``` Snoring Tiredness during day Obs apnea Pressure -increased BP BMI >35kg/m^2 Age >50 Neck circ >40cm Gender male ``` * one point for each * Low for OSA < 3pts * adequate/need more testing 3-6 pts * > = 5 pts - High likelihood for OSA

HbA1C

``` gives indication of how well the DM is being controlled over time -erythrocytes 120 day lifespan -norm <6% - levels <7% considered controlled - ```

How much of a reduction in insulin should you make day of surgery to prevent hypoglycemia d/t fasting?

30-50%

Biguanide example

Metformin

Metformin should be stopped how many hours pre-op? | Why?

48 | *reduce risk of Fatal Lactic Acidosis

S/S of Biguanide induced lactic acidosis are:

``` nonspecific and include: anorexia n/v AMS hyperpnea (rapid deep breathing) abd pain thirst *Presenting with ACIDOSIS (w/o hypoperfusion or hypoxia) ```

TX of biguanide -induced lactic acidosis:

withdrawal of biguanide adequate hydration/circulatory support correction of acidosis HD (for acid/base control; drug clearance)

Explain 1800 Rule

Divide total daily insulin dose into 1800 - to calculate how many points of glucose 1 unit of insulin (rapid) will lower. * 1800/30units = 60 mg/dL gives us an idea where to start

Preferred method of insulin administration?

SubQ - slower, steady control - avoid wide swings in glucose levels * will see IV used

Patients with treated HTN who undergo surgery have as much as 50% increased risk....

of MI / cardiac arrest or significant new dysrhthmia in the first 30 days post-op

ACE inhibitors are associated with ____ a

Profound Hypotension *many of these pts will have increased post-op morbidity/mortality rates (30% will have problems with low BP, 10% will be resistant to other methods (Neo/Levo)

ACEI and Angiotensin II receptro subtype -1 antagonists (Cozaar, Diovan) should be d/c'd within how many hours of induction?

10 hours

To treat profound hypotension in GA from ACE inhibitors, what would you do?

Vasopressin 0.4-0.8mcg (1-2 units --> 1unit/ml) **if vasopressin not working --> methylene blue

Important factors to monitor for pt who's been on antihypertensives

- EKG - Trends (bp, hr, etc) - keep BP w/in 20% of baseline

OP center concerns for Morbidly Obese patients

- increased co-morbidity - OSA - Need referral for airway, pulm, and sleep d/o - airway, cardiopulm, and endocrine evaluations are appropriate for BMI >35 kg/m2. - Onsite airway eval imperative

airway, cardiopulmonary, and endocrine evaluations are appropriate for patients with a BMI :

>35 kg/m2

What creates sympathetic neural activation and leads to HPTN and CV abnormalities that can cause morbidity and sudden death?

OSA

A Hospital setting is more appropriate for this type of patient:

Appears or is known to have moderate or severe OSA and is UNTREATED and will require opioids for pain.

*** Upper Respiratory Infection *** Airflow obstruction has been shown to be persist for how many weeks in adults?

up to 6 weeks therefore surgery should be delayed 6 weeks from onset of URI

*** Upper Respiratory Infection *** When would you delay a surgery in Children with URI?

Cancel if symptomatic; 2 weeks may be enough *but may develop again w/in 2 weeks. URI has not been show to increase LOS after procedures in children

Risk Factors for adverse respiratory events in children with URI's include:

- HX of Parental Smoking ** - Presence of Copious Secretions ** - use of ETT/LMA or Face mask - hx of prematurity - hx of reactive airway disease - surgery involving the airway - nasal congestion

It's generally appropriate to proceed with planned procedure if a pt with URI does not have:

a FEVER (101 + no surgery)

Prevention of PONV is best by

Increasing fluids adults immediate post-op should receive 20ml/hr of LR for each hour fasted over 20 mins.

Different modes of medication to prevent PONV

zofran, decadron (dexamethasone), reglan, scopolamine * if still n/v post-op, phenergan 6.25mg IV * Doperidol (B.Box warning for enlongated QTC)

Concerns with giving Phenergan IV?

infiltration - tissue damage | sedation in higher doses

This combination decreases PONV in pediatrics by 80%:

hydration a dual prophylaxis with Zofran and dexamethasone *repeated doses of zofran in adults were less effective (promethazine!)

Patients place a high value on the prevention of PONV ranking it equivalent to prevention and tx of ____.

Pain

Scoring system used to direct prophylaxis against PONV

Apfel's

Outpatient Surgery Flashcards

(56 cards)