Ambulatory

Question 1

What surgery locations are considered ambulatory?

Answer 1

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

Question 2

What are the four different facility design types?

Answer 2

• 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

Question 3

How are patients selected for SDS?

What criteria do they need to meet?

Answer 3

• 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

Question 4

What are the ASA recommendations for OSA patients and SDS?

Answer 4

• 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

Question 5

What factors increase need for post op admission following SDS?

Answer 5

• > 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

Question 6

What are contraindications for SDS?

Answer 6

• 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

Question 7

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

Answer 7

• <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

Question 8

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

What are the NPO guidelines?

Answer 8

• 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

Question 9

What medications should be given pre-operatively?

How is anxiety controlled?

Answer 9

• 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

Question 10

What are the risk factors for PONV?

Answer 10

• 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

Question 11

How can PONV be prevented?

Answer 11

• 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!

Question 12

What are the standards of care for outpatient surgery?

What are the qualities of the ideal outpatient anesthetic?

Answer 12

• 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

Question 13

How do you manage pain for the ideal outpatient anesthetic?

Answer 13

• 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)

Question 14

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

(6)

Answer 14

• 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

Question 15

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

Answer 15

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

Question 16

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

Answer 16

• 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

Question 17

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

Answer 17

• 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

Question 18

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

What are some key concepts?

Answer 18

• 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)

Question 19

Why is thermoregulation difficult in plastic surgery population?

Answer 19

• 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

Question 20

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

Answer 20

• 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

Question 21

What is monitored anesthesia care?

When is it done?

Answer 21

• 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

Question 22

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

Answer 22

• 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)

Question 23

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

Answer 23

• 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

Question 24

What is the discharge criteria for a SDS patient?

Answer 24

• 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

Question 25

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

Answer 25

* drowsiness- residual sedation * nausea * pain