NORA

Question 1

Pros of ambulatory/office anesthesia

Answer 1

1. cost 2. free up hospital beds 3. decrease waiting times 4. minimizes separation of children from parents 5. POCD decreased in elderly 6. benefit to staff: more uniform hours, and more predictable surgical outcomes

Question 2

cons of ambulatory and office based anesthesia

Answer 2

1. difficult to assess adequate post op care / compliance 2. more trips for pt to pre-op clinic for testing 3. less time to monitor pts for post-op complicatiosn 4. less time for children to build relationship/trust with provider

Question 3

goals of ambulatory anesthesia

Answer 3

1. provide fast, smooth onset of anesthesia 2. minimize s/e 3. allow rapid offset by using rapid acting, short half life drugs 4. provide analgesia and amnesia 5. get pts home quickly and back to regular eating and sleeping schedules

Question 4

surgeries that appropriate for the outpatient setting?

Answer 4

1. those without frequent complications 2. those without a lot of post-op maintenace 3. those that are not associated with lg EBL/fluid shifts

Question 5

patient status that is appropriate for outpatient anesthesia

Answer 5

1. physical status stable for at least 3 months 2. medical issues not c/i for outpatient 3. pt has access to assistance at home/caregiver over night

Question 6

surgeon skills/cooperation that is appropriate for outpatient anesthesia

Answer 6

1. early referral to anesthesia for judgement of questionable patients 2. take into consideration skills and speed of surgery 3. anesthesia plan

Question 7

what patients/situations are NOT appropriate for outpatient surgery/anesthesia

Answer 7

1. Unstable ASA physical status classification (III/IV) 2. active substance/etoh abuse 3. psychosocial difficulties: caregiver not avail to observe on evening of surgeyr 4. poorly controlled seizures 5. morbidly obese with severe comorbidities 6. previously unevaluated and poorly managed mod to severe OSA 7. ex premature infants < 60 wks gestational age 8. uncontrolled DM 9. current sepsis or infectious dz requiring separate isolation 10. post op pain not expected to be controlled with oral or local analgesics

Question 8

as an anesthesia provider, what questions would one ask for providing services in a new ambulatory facility or office?

Answer 8

1. is the facility licensed? by whom? 2. is the facility accredited? by whom? 3. size of OR, recovery room, and preop are adequate for anesthesia and surgical procedures 4. is there a transfer agreement? 5. does the facility have an emergency service agreement? 6. available communication resources: telephone numbers accessible and posted for: EMS, MH hotline, and nearby hospital

Question 9

special considerations with outpatient anesthesia: sickle cell dz

Answer 9

1. ask all AA 2. no sickle cell crisis within 1 year 3. must be followed closely post-op 4. pt should live within 15 min of hospital or facility that can care for them 5. pt should be compliant with prescribed medical care

Question 10

what is the test for sickle cell

Answer 10

sickledex

Question 11

T/F: pts with sickle cell trait are still high risk for outpatient anesthesia

Answer 11

TRUE

Question 12

sickling with sickle cell pts occurs with?

Answer 12

1. hypoxia 2. dehydration 3. hypothermia 4. stress 5. pain

Question 13

who is susceptible to malignant hyperthermia (in outpatient setting)?

Answer 13

1. those with previous episode 2. massester rigidity 3. first degree relative with positive biopsy 4. dzs with known mutations to chromosome 19 5. heat induced rhabdomyolysis

Question 14

what dzs have known mutations to chromosome 19 which make them more susceptible to malignant hyperthermia

Answer 14

1. central core myopathy 2. native american myopathy 3. hypokalemic periodic paralysis 4. king denborough dz

Question 15

there must be ____________ vials of dantrolene available in the outpatient setting in the case of malignant hyperthermia

Answer 15

36

Question 16

if a patient develops malignant hyperthermia in the outpatient setting, what should you do?

Answer 16

1. help to draw up vials of dantrolene 2. emergency transfer to hosptial

Question 17

s/sx of malignant hyperthermia

Answer 17

1. increased HR and BP 2. masseter rigidity 3. dark urine 4. increased EtCO2 5. elevated Temp (late sign)

Question 18

if a patient presents to outpatient setting for surgery and you ask why they have their pacemaker, and their response is “to prevent my heart stopping” or “to prevent lethal arrhythmias” how should you proceed

Answer 18

cancel the case - this pt’s procedure should only be done in the hosptial

Question 19

what is the most common interference to pacemakers and AICDs

Answer 19

monopolar electrocautery

Question 20

if a patient presents to the outpatient setting for surgery/anesthesia with a cardiac electronic device, what questions should you ask them about it?

Answer 20

1. why do you have the device 2. are there underlying issues 3. how often are you paced?

Question 21

if a pt presents with pacemaker to outpatient surgery, what things must the anesthesia provider ensure?

Answer 21

1. there is over 3 months of battery left on pacemaker (through records) 2. a magnet is readily available for the surgery 3. if bipolar cautery is used grounding pad is below the umbilicus 4. pacer should have been interrogated in the last year

Question 22

anesthesia should ensure of what things when a pt presents for outpatient surgery with an AICD

Answer 22

1. magnet available for surgery 2. AICD was integrated within last 6 months (identify through records) 3. bipolar cautery is used, grounding pad below umbilicus

Question 23

how do you know a magnet has placed an AICD or pacemaker in asynchronous mode

Answer 23

you will put your stethoscope down and hear beeping

Question 24

T/F: uncomplicated morbidly obese patient is an appropriate candidate for select outpatient surgery

Answer 24

TRUE

Question 25

questions to ask when pt presenting for outpatient surgery/anesthesia is obese?

Answer 25

1. are there comorbidities optimized? 2. do they use CPAP machine? 3. how invasive is the surgery? 4. is the surgery associated with high post-op pain which requires opioids?

Question 26

STOP-BANG score of > ________ is highly suggestive of OSA?

Answer 26

3

Question 27

you can safely do outpatient surgery/anesthesia in the obese patient with BMI of = ___________

Answer 27

44

Question 28

when is the outpatient surgery, pre-op anesthesia assesment usually performed

Answer 28

day of surgery

Question 29

what questions do you ask in a pre-op pt phone interview for patient presenting for outpatient surgery?

Answer 29

1. any cardiac issues? - MI in the past 60 days? 2. cardiac clearance - implanted devices? Able to lie flat? SOB? 3. any pulmonary issues? smoking hx 4. neuro - SC injury? MG, MS, MD, strokes, brain tumor, dementia or seizures? 5. DM? thyroid issues? 6. any blood thinners or coagulation dz? 7. cancer? 8. addiction issues? 9. anesthesia issues? - difficult airway, trach, prolonged intubation, MH

Question 30

what is the number one reason for hospital admission after outpatient anesthesia?

Answer 30

nausea and vomiting

Question 31

what is the 2nd most common reason for hospital admissions after outpatient anesthesia?

Answer 31

pain

Question 32

a pt presents for outpatient surgery, and has chronic pain, you know this patient may have to be admitted to the hospital post-op due to what?

Answer 32

1. over sedation issues 2. inadequate pain control

Question 33

most common pediatric outpatient surgeries?

Answer 33

1. myringotomy 2. tonsillectomy 3. adenoidectomy

Question 34

outpatient, pediatric ear tube surgery (myringotomy), are very fast thus can be done with or without __________________

Answer 34

PIV

Question 35

pediatric outpatient dental procedures, anesthesia considerations

Answer 35

1. N20 2. oral midazolam 3. some may have to have full oral rehab requiring ETT 4. some surgeries require throat packs (aspiration)

Question 36

outpatient anesthesia considerations for the pediatric strabismus surgery/eye muscle surgeries

Answer 36

high incidence of postop N/V

Question 37

outpatient pediatric orthopedic procedure anesthetic technique

Answer 37

1. MAC 2. regional 3. LMA 4. ETT

Question 38

pediatric outpatient preop

Answer 38

1. check teeth for food/gum to ensure NPO status 2. allergies - ask about balloons at bday parties for latex 3. any congenital heart issues? - if yes, are they corrected? 4. ASthma? when was last exacerbation? 5. Acute respiratory infection?

Question 39

pediatric outpatient preop may be done over the phone with parent if the child is a ASA ___________ or _________

Answer 39

I/II

Question 40

pediatric outpatient pre-op assessment the parent says the childs last asthmas exacerbation was 2 weeks ago, how should you proceed?

Answer 40

delay or move surgery to inpatient - last exacerbation cannot be within a month for outpatient setting

Question 41

in pediatric outpatient pre-op assessment the pt has what looks like cookies in their teeth, how should you proceed?

Answer 41

delay for 8 hours minimum

Question 42

what is the risk with doing a pediatric outpatient procedure if they have had an upper respiratory infection in the last 6 weeks?

Answer 42

more likely to have some kind of airflow obstruction

Question 43

why are surgeries on premie babies that are under 50-60 weeks post gestational age not done in the outpatient setting?

Answer 43

1. apnea risk d/t immature brainstem/periodic breathing --> apnea up to 12 hours 2. anemic associated apnea 3. immature temperature control

Question 44

T/F: PACU must be available to recover the outpatient pediatric patient post op or you have to stay with the pt until PACU RN is available

Answer 44

TRUE

Question 45

Advantages to regional anesthesia in ambulatory surgery?

Answer 45

1. peripheral nerve block recovery times are shorter than with GA 2. unanticipated admission to the hospital is reduced 3. phase I recovery bypass eligibility is high 4. provides adequate postop pain relief and better than with GA 5. good alternative for pt who does not like loss of control with GA

Question 46

what are some guidelines of outpatient plastic surgery?

Answer 46

1. pt must have compression stockings on prior to induction 2. ASA I and II appropriate 3. ASA III must be seen preoperatively 4. females of menstrual age = blood hcg NOT urine 5. if surgery >4 hours, foley placement

Question 47

Anesthesia considerations with breast augmentation

Answer 47

1. secure arms when sitting up to check breast symmetry 2. Local MAC or GA appropriate

Question 48

anesthesia considerations with nose reshaping/rhinoplasty

Answer 48

1. can be difficult mask ventilation d/t no pressure allowed on the nose 2. Oral RAE ETT 3. Local MAC

Question 49

anesthesia considerations with facelift, midface, or neck plastic procedure

Answer 49

1. local MAC or GA 2. full face/neck procedure - no LMA d/t disortion of neck 3. must keep HD stable at conclusion of the case 4. multimodal PONV control 5. HOB 90 degrees

Question 50

rule of thumb on EBL with liposuction?

Answer 50

blood loss = 1% of aspirate

Question 51

complications with liposuction

Answer 51

1. local anesthetic toxicity 2. PE/DVT 3. massive fluid/electrolyte shifts

Question 52

liposuction aspiration must be limited to ________ L

Answer 52

5

Question 53

peak lidocaine levels after liposuction are ___________ hours after injection

Answer 53

14-Dec

Question 54

what is the maximum lidocaine dose for office based liposuction

Answer 54

7 mg/kg

Question 55

what is the tumescent liposuction technique

Answer 55

1. 1 L of LR or NS with epi 1:1,000,000 and lidocaine 0.025-0.1% 2. you do 1-4 mL of the infiltrate above per 1 ml of fat removed

Question 56

___________________ is the most cardio-toxic local anesthesic

Answer 56

bupivicaine

Question 57

what is local anesthetic systemic toxicity (LAST)

Answer 57

1. when large amounts of local anesthetic reach systemic circulation 2. likely to cause cardiac toxicity d/t electrophysiological and contractile dysfucntion

Question 58

what are the early s/sx of local anesthetic systemic toxicity (LAST)

Answer 58

1. perioral numbness 2. tinnitus 3. agitation 4. confusion

Question 59

what are the late s/sx of local anesthetic systemic toxicity (LAST)

Answer 59

1. CNS depression 2. seizures 3. coma 4. complete CV collapse

Question 60

how do you tx pt with Local anesthetic systemic toxicity (LAST)

Answer 60

1. supportive care 2. infusion of 20% intralipid emulsion

Question 61

if your patient is > 70 kg, and you suspect LAST, how would you administer the lipid emulsion infusion

Answer 61

1. bolus 100 mL over 2-3 min 2. infusion of 200-250 mL over 15-20 min

Question 62

if you patient is < 70 kg and you suspect LAST, how would you administer the lipid emulsion infusion?

Answer 62

1. rapid bolus of 1.5 mL/kg over 2-3 min 2. infusion of 0.25 mL/kg/min

Question 63

anesthetic considerations for dental anesthesia

Answer 63

1. state dental boards requirements for dentist to hold sedation permits may limit the types of drugs that can be administered by CRNA 2. shared airway 3. throat packs must be changed before they are saturated 4. trigeminal nerve pain may require more sedation 5. glycopyrolate may be necessary 6. no water boarding 7. HOB > 30 8. dentists/surgeons are not doing anesthesia preop - thus CRNA must perform it