True/False
Your patient is a preterm infant scheduled to have a simple outpatient procedure. True or False: This patient is appropriate for the outpatient setting
False: preterm infants are prone to respiratory issues, specifically apnea, and should not be operated on in the outpatient setting
Your patient is a 62 yo male here for an outpatient colonoscopy with a BMI 43.2 BP 170/100 with a BG of 129 and a new diagnosis of HF last week. How would you like to proceed?
Cancel! Do not operate on patients with: decompnesated, new onset or untreated HF. They homies need to be optimized before proceeding to ambulatory surgery
Name four surgeries that might be done as an outpatient procedure:
cataracts, septoplasty, tonsillectomy/ adenoidectomy, joint arthroscopy/ arthroplasty, laproscopic cholesystectomy, wound debridement, myomectomy, hernia, rotator cuff, skin and breast, colonoscopy/EGD, myringotomy, pacemaker, therapeutic injection (steroid, opioid)
Patients with mild or asymptomatic valvular disease are:
a) a ticking time bomb, pass
b) usually at low risk for perioperative complications and may be appropriate candidates for outpatient procedures
c) very likely too high risk for outpatient surgery and should be managed at a full-service hospital
b
True/False: new onset a-fib is associated with increased risk for morbidity and mortality
True! slide 21
True/False: COPD is an independent risk factor for adverse outcomes after ambulatory surgery.
True
Your patient is a 45 year old woman here for wound debridement under MAC which chronic a-fib that is currently managed on PO amio by their cardiologist. How do you want to proceed.
Barring other concerning hx, full steam ahead! Chronic a-fib that is optimized is reasonable for outpatient surgery
symptomatic heart conditions are not (fatigue, dizziness, syncope, palpitations, CP, and SOB)
Tyler lists four disadvantages to outpatient anesthesia, name two of them:
- Inconvenient with complex past medical history
- Social support: need a ride home (cannot be ride share)
- unanticipated admission/transfer: harder to get them to a hospital bed
- Last minute cancellations: less of a backfill like there would be in a hospital setting
Which of the following is NOT a criterial for severe aortic stenosis?
a) valve area < or = 1 cm2
b)mean pressure gradient <20
c)maximum flow velocity <4 m/s
d) mean pressure gradient >40
b)
slide 22
What is the ceiling for BMI at which your patient will still likely tolerate ambulatory surgery?
<40 kg/m2
At a BMI of >50kg/m2 there is a significantly greater risk for post-op complications and a greater risk for m and m
True!
However if they have a change in their baseline O2 needs, they might not be a great candidate
Metabolic syndrome seen with obesity leads to changes in what four things?
(sorry bit of a tough one)
- oxygen demand
- CO2 production
- alveolar ventialtion
- CO
slide 24
Which of these factors likely makes a patient inappropriate for an outpatient procedure? (select all that apply)
a) acute substance abuse
b) extreme bitchiness (uncooperative or unreliable)
c) History of MH
d) Type II DM
e) morbid obesity
f) M/W/F HD dialysis
a) b) c) e)
Your patient is a 52 year old woman coming in for an intra-abdominal surgery with a history of well-controlled HTN, ESRD, GERD, and excessive flatulence. Which of these factors is the biggest no-no for outpatient surgery and why?
ESRD: large shifts in fluid and electrolytes during an abdominal surgery could be very dangerous for this patient
Your patient is an ESRD patient who is well controlled and is here for cataract surgery. What lab do you want to get? What is one medication you might avoid?
- day-of potassium
- avoid succs for its effect on K
slide 26
True or False: Patients undergoing procedures of low invasiveness do not require cardiac testing because the risk of cardiac complications after this type of outpatient surgery is very low (<1%).
True!
slide 20
What are three advantages for using local anesthesia with out patient procedures?
- protective airway reflexes are maintained
- fast recovery
- allows for patient participation
slide 39
Which BPs would result in a cancellectomy?
a) SBP >200
b) BP 175/110
c) DBP > 100
d) BP 200/115
a) and d)
SBP >200
DBP >110
<180/110 may be reasonable for elective surgery
Your patient had a stroke 2 months ago and has full function back/no deficits. How long should they wait for elective surgery?
a) because they have no deficits they are okay to have surgery now
b) 6 months total
c) 9 months total
d) no more surgery for you boo
c) 9 months total
slide 27
Name some potential disadvantages to regional anesthesia:
- Potential for failed block; time (need to be able to fall back on GA)
- Patient awareness (might allow them to be more awake than they are comfortable with)
- Impaired mobility & prolonged motor block (what assistance is available to them?)
- Sympathetic block (hypotension after SAB)
- Urinary retention
True/False: An unplanned admission is any readmission to the same or another hospital for a postoperative occurrence likely related to the principal surgical procedure within 30 days of the procedure
True
slide 47
vitals, ambulation, N/V, pain, bleeding, voiding
You want a score greater than 9
Which of the following are advantages of general anesthesia in outpatient procedures (select all that apply)
a) PONV
b) intraoperative patient comfort
c) guaranteed unconsciousness/amnesia
d)sore throat
e) good for uncooperative patient
b) c) and e)
Which of the following is NOT an appropriate procedure for outpatient?
a) lung wedge resection
b) procedure lasting less than 90 mins
c) procedures with no interference with postoperative ambulation
d) procedures with minimal risk of postoperative airway obstruction
a)
slide 35
Which of the following is NOT one of the Aldrete scoring categories?
a) circulation
b) pain
c) activity
d) conciousness
e) oxygen saturation
f) respiration
**bonus: what is usually a score that is safe for discharge
b) pain
(activity, respiration, circulation, conciousness, oxygen sat)
score equal to or greater than 9 is usually GTG