Principles outpatient anesthesia Flashcards
(44 cards)
Advantages of outpatient anesthesia
Financial, medical, patient satisfaction, social, staffing.
Disadvantages of outpatient anesthesia
Less patient privacy than in the inpatient setting.
The patient may be required to make multiple trips to the physician’s office or the ambulatory setting for preoperative evaluation and screening.
Adequate home care must be coordinated after patient discharge.
Compliance with preoperative and postoperative instructions may not be as good as when patient is in the inpatient setting.
Demographic considerations
Patient Age:
Patients of any age can undergo outpatient surgical procedures
Surgical Time:
Arbitrarily limiting expected surgical times to 2 hours is no longer considered necessary
Suitable Procedures:
Constantly evolving
Patient selection
Proper patient selection reduces number of hospital admissions after outpatient surgery
Primary predictors of hospital admission are related to:
The type of surgical procedure, subsequent complications, PONV, pain, significant operative fluid shifts or blood loss
Factors to consider when determining if a patient is suitable for outpatient surgery:
The anticipated surgical procedure, the physical and psychosocial health of the patient, the surgeon’s skill and cooperation
Primary predictors of hospital admission are related to:
The type of surgical procedure
Subsequent complications:
PONV
Pain
Significant operative fluid shifts or blood loss
Factors to consider when determining if a patient is suitable for outpatient surgery:
The anticipated surgical procedure
The physical and psychosocial health of the patient
The surgeon’s skill and cooperation
Premature infant (gestational age 37 weeks or less at birth):
Inappropriate for outpatient surgery because of potential physiologic aberrations:
Anemia
Gag reflexes not fully developed leading to increased risk of aspiration
Immature temperature regulation
Immature brainstem function, increasing risk of pathologic respiratory conditions
Acute Substance Abuse:
Urine drug screen if drug use suspected
If acute substance abuse, reschedule
Full-term infant:
Healthy full-term infants may be considered for minor outpatient procedures
Not appropriate:
Hx of apneic episodes
Failure to thrive
Feeding difficulties
Respiratory difficulties at birth
Geriatric patients (> 65 years old):
Individualized, based on physiologic age (not chronologic age)
Ensure appropriate home care and transportation to/from the surgery center
Convulsive Disorders:
Schedule surgery early in the day so patient can be observed 4-8 hours postoperatively
Maintain patient’s anticonvulsant schedule
Uncontrolled seizures: NOT appropriate for OPS
Malignant Hyperthermia Susceptibility:
Definition:
Previous MH episode
Masseter muscle rigidity with previous anesthetic
1st degree relative with a history of MH or positive muscle biopsy
Diseases with known mutations on chromosome 19: central core myopathy, King-Denborough syndrome, Native American myopathy, and hypokalemic periodic paralysis
Patients with heat-induced rhabdomyolysis
Morbid Obesity:
BMI > 35-40 no longer limited
*Thorough preoperative airway evaluation is vital
Obstructive Sleep Apnea:
Instruct patient to bring CPAP machine for postoperative recovery phase
OSA patients with nonoptimized comorbid medical conditions may not be good candidates for OPS
Reactive Airway Disease:
Patient should be medically optimized
Sickle Cell Disease:
Criteria:
No major organ disease due to sickle cell
No sickle cell crisis within last year
Patient must be compliant with prescribed medical care
Patient should reside within 15 minutes of a facility prepared to care for him/her
Patient should receive close follow-up postoperative care
Social Considerations:
Patient compliance
Presence of responsible caregiver
Discharge accommodations
Access to assistance
Financial and insurance considerations
Unacceptable patient conditions for ambulatory surgery:
Unstable ASA physical class III or IV (cardiac, renal, hepatic, endocrine, pulmonary, or cancer diagnoses)
Active substance abuse
Psychosocial difficulties (caregiver not available to observe patient the evening of surgery)
Poorly controlled seizures
Morbid obesity with significant comorbid conditions (angina, asthma, OSA)
Previously unevaluated and poorly managed moderate to sever OSA
Ex-premature infants < 60 weeks postconceptual age requiring GETA
Uncontrolled diabetes
Current sepsis or infectious disease requiring isolation facilities
Anticipated postoperative pain that will not be controlled with oral analgesics and/or local anesthesia techniques
Thorough medical exam and history should be taken:
Medically stable patient: within 30 days of procedure
High-risk patients: within 72 hours of the procedure
Chest Radiography should occur with
New pulmonary signs or symptoms
End-stage renal disease
Decompensated heart failure (if tests might change patient management or outcome)
Electrocardiography:
Routine EKG is not required
Not cost effective and is a poor predictor of perioperative outcomes
Pregnancy test for menstruating females under 13
No test unless patient sexually active or inconclusive
Pregnancy test
Should be offered to all patients except those with a hysterectomy or bilateral salpingo-oophorectomy
serum test preferred, urine test sufficient
Fasting status and aspiration risk
clear liquids - 2 hrs
breast mile - 4 hrs
infant formula - 6 hrs
non human milk - 6 hrs
light meals - 6 hrs
heavy meal/fried/fatty - 8 hrs
