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Advanced Principles- Fall 2018 > Ambulatory > Flashcards

Flashcards in Ambulatory Deck (25)
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1
Q

What surgery locations are considered ambulatory?

A
  • Ambulatory
  • same day surgery
    • must be admitted and d/c on same calendar day
    • 23 hour is a “short stay”
  • outpatient surgery
2
Q

What are the four different facility design types?

A
  • Hospital integrated- usually with 24 hr OR/PACU
    • same facility as inpatients
    • SDS pts may have separate pre-op or recovery area
    • SDS pts may get bumped for emergencies
  • Hospital based
    • separate ambulatory facility within a hospital. Everything separate
  • freestanding
    • no next shift, very efficient with short turnovers
    • if unplanned admission required, pt must be transported
  • office based
    • recovery of patient can be an issue/responsibility of CRNA
3
Q

How are patients selected for SDS?

What criteria do they need to meet?

A
  • Now based on degree of physiologic disturbance instead of length of procedure
    • N/V extends hospital stays more often than long surgical time
  • SDS can be offered more commonly now that we have:
    • less invasive surgical techniques
    • better pain control methods
    • shorter acting anesthetics
    • no longer assume pts are better off in hospital
  • Surgical procedure
  • physiologic response
    • potential for blood loss, pain, PONV, major fluid shifts–too much not ideal for SDS
  • Pain management
    • regional- good option but prolonged immobilization not ideal for pt alone at home
    • pts requiring opioids may require 23 hr stay
  • ASA classification I & II (possibly III and IV if medically stable)
  • Extremes of age not ok for SDS
    • <6mo or >70 years
4
Q

What are the ASA recommendations for OSA patients and SDS?

A
  • SDS ok in pt with OSA if surgery is superficial or minor ortho with local or regional
  • SDS is “equivocal” for superficial surgery with GA, tonsillectomy for >3 yrs old, or gynecologic laparoscopic procedures
  • Avoid SDS for airway surgery, tonsilectomy < 3years, and upper abdominal laparoscopic
  • ***consider need for opioids
  • **chest and airway surgery at higher risk with OSA
5
Q

What factors increase need for post op admission following SDS?

A
  • > 65 years old
  • OR time > 120 minutes
  • CV diagnosis (CAD, PVD, ect)
  • Malignancy
    • Higher concern for bleeding
  • HIV
    • HIV pts behave physiologically much older than they look physically d/t the meds they take
6
Q

What are contraindications for SDS?

A
  • uncontrolled systemic disease
    • DM
    • unstable angina
    • severe asthma
    • Pickwickian (OHS)
    • pain, etc
  • Central acting therapies
    • MOAI’s & cocaine
  • morbid obesity + symptomatic CV or pulmonary disease
  • Lack of support at home post operatively
    • cannot drive themselves home
    • live close enough to return to hospital
7
Q

What are the guidelines for outpatient surgery of neonates/infants?

A
  • <46 weeks post conceptual age = 12 hours of monitoring
  • 46-60 weeks post conceptual age with comorbidity = 12 hours of monitoring
    • cardiac
    • pulmonary
    • documented apnea
    • neuroogic disease
    • anemia (Hct <30%)
  • 46-60 weeks post conceptual age with no co-morbidity = 6 hours of monitoring
  • ***caffeine can reduce risk of post-op apnea in infants
8
Q

How is a pre-op assessment done for same day surgery?

What are the NPO guidelines?

A
  • Pre-op assessment must meet the same standards as for in-patients
  • Ideal to come to pre-op clinic, not always realistic
    • can do phone interview instead
  • NPO guidelines:
    • clears- 2 hours
    • breastmilk- 4 hours
    • non human milk/formula- 6 hours
    • light solid meal- 6 hours
    • heavy meal- 8 hours
9
Q

What medications should be given pre-operatively?

How is anxiety controlled?

A
  • Continue with current regimen with small sip of water up to 30 minutes before
  • Midaz- controversial
    • current evidence says it helps with anxiety, pain, and nausea without prolonging discharge
    • decreaseases requirement of propofol
  • pre-op directions and education
10
Q

What are the risk factors for PONV?

A
  • type of anesthetic technique
    • opioid use
    • inhaled agents
    • anticholinesterase
    • hydration status
    • hypotension
  • Type of surgery
    • length of procedure
    • pain management
    • gastric distension
  • Patient factors
    • hx of PONV and motion sickness
    • anxiety
    • non-smoker
    • within 1 wk of menstural cycle
    • age
    • genetic predisposition
11
Q

How can PONV be prevented?

A
  • Droperidol- low dose 0.625-1.2
    • black box prolonged QT risks are associated with higher doses
  • Dexamethasone: 4-8 mg
  • 5-HT antagonists:
    • Ondansetron 2-4 mg
    • Dolasetron 12.5 mg
  • Promethazine/phenergan 6.25-12 mg
    • may prolong awakening
  • Metoclopramide: 10-20 mg
    • can cause extrapyramidal side effects, give at beginning of case
  • Antihistamines
  • Neurokinin 1 antagonists (aprepitant)
    • longer acting and synergistic with zofran
    • interferes with substance P
  • propofol and midazolam
    • antiemetic properties outlast sedative effects
  • scopalomine patch
    • 1 mg over 3 days, not effective for first 2-4 hours after application
  • hydration
  • Accustimulation at P6 acupoint
    • can be more effective than drugs!
12
Q

What are the standards of care for outpatient surgery?

What are the qualities of the ideal outpatient anesthetic?

A
  • Same as inpatient surgery
    • ECG, BP, pulse ox, capnograph
  • Ideal outpatient anesthetic:
    • rapid ans smooth onset
    • intraoperative amnesia and analgesia
    • good surgical conditions with short recovery
    • no adverse effects
13
Q

How do you manage pain for the ideal outpatient anesthetic?

A
  • Use opioids carefully b/c they cause resp depression and increase N/V
  • Consider continuous PNB
  • Perineural, incisional, and intraarticular catheters with continuous balloon pump
    • have been reported to cause chondrolysis (severe joint arthritis)
14
Q

What do you need to consider regarding Epidural and spinal anesthesia for SDS patients?

(6)

A
  • Better post op pain with shorter pacu stays, but that is balanced out by longer time in pre-op
  • Success rate is not 100%
  • can cause side effects like HA and backache
  • Can use mini doses with added narcotics for quicker recovery
  • Consider shorter acting agents like chloroprocaine
  • need to follow up with call to rule out HA
15
Q

How does the addition of fentanyl to a neuraxial block affect it?

A

It prolongs sensory but not moror blockade and appears to decrease the time to voiding and full recovery

16
Q

What do you need to consider regarding Peripheral nerve blocks and SDS patients?

A
  • Bier block is short acting but ineffective 11% of the time
  • Good for PONV
  • risk of verve/vessel injury
  • can fail, depends on provider experience level
17
Q

Even with motor recovery, how long might functional balance be impaired for?

A
  • 150-180 minutes after spinal anesthesia
  • After complete recovery of motor, residual sympathetic blockade and orthostatic hypotension are less likely to be a problem on ambulation
18
Q

What is the most widely used anesthetic technique for ambulatory surgery?

What are some key concepts?

A
  • General anesthesia
  • Key concepts for SDS:
    • minimize physiologic stress and adaptation
    • use short acting agents
    • don’t over muscle-relax
  • Maintain thermoregulation (big problem in plastic surgery patients)
19
Q

Why is thermoregulation difficult in plastic surgery population?

A
  • volatile agents vasodilate
  • can have large 3rd space losses/exposure
  • can be lengthy
  • difficult to place a BAIR hugger if sterile prepped area is large
  • BAIR controversial due to cost for procedure <90 minutes
20
Q

What are some considerations for the maintenance phase of a SDS patient?

A
  • Consider TIVA vs inhaled agent to decrease risk of PONV
    • propofol and versed have antinausea properties
  • Opioids:
    • Alfentanil has more rapid onset and shorter duration than fentanyl, making emergence and recovery of psychomotor function faster
    • Remifentanil is ultrashort, not good for painful cases d/t lack of post-op coverage
21
Q

What is monitored anesthesia care?

When is it done?

A
  • Anesthetic management of a case where patients remain responsive and breathe without assistance
  • Used for simple procedures and minor surgery
  • May include LA infiltration, sedatives, analgesics, etc.
  • Standard of care is SAME as for GA or RA
22
Q

What are the criteria for “fast tracking” a MAC patient?

A
  • awake, alert, and oriented
  • able to move extremities on command
  • VS within 15-20% of normal
  • SaO2 >94% on RA
  • able to breathe deeply
  • no pain, nausea, or vomiting
  • 5 second head lift (if NMB given)
23
Q

What are some considerations for the post-operative period of a SDS patient?

A
  • Management of pain and nausea–address preoperatively and throughout case
    • LA infiltration
    • perineural catheters
    • Ketamin at induction
    • ketorolac at emergence
    • hydration
    • anti emetics
      • inhalational alcohol
      • 10-15 mg propofol
  • Goal: to facilitate rapid conversion to oral analgesics
    • warn pt when the regional will ware off
  • Goal: avoid emesis in the car
24
Q

What is the discharge criteria for a SDS patient?

A
  • Usually based on a scoring system that evaluates the ability to tolerate fluids, void, walk, VS stability, bleeding, pain and nausea
    • criteria is controversial–voiding often not required
  • remind pt no driving, no power tools, and no business decisions for 24 hours
  • written and oral instructions to pt and responsible adult to accompany pt home
25
Q

What are the three most common causes of delay of discharge from SDS?

A
  • drowsiness- residual sedation
  • nausea
  • pain