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ICPAP Test 4

Terms in this set (227)

it shifts upwards and outwards
What changes with the diaphragm from standing to supine?
they move cephalad, and posterior to the diaphragm
What changes with the abdominal contents from standing to supine?
they decrease 20-25% (may fall below closing capacity in the elderly)
What changes with TLC and FRC from standing to supine?
more, lower
Someone who is standing is able to get ____ volume for ____ pressure compared to someone who is lying down.
venous return increases causing a transient increase in CO but the atrial stretch receptors will kick in and cause the baroreceptor reflex to kick in (slight to no change overall)
What changes with venous and atrial pressures from standing to supine?
increase
d/t depressive effects of medications
loss of muscle tone
abnormal pressures
loss of ANS control
Anesthesia can ___ risk of respiratory and CV compromise d/t what?
elevated diaphragm
decrease chest wall and lung compliance
respiratory center depression
What respiratory changes occur under anesthesia?
direct myocardial depression
depression of ANS receptors
What cardiovascular changes occur under anesthesia?
compensatory sympathetic nervous system reflexes
Positioning and anesthesia combined will blunt ____ that would normally minimize systemic BP changes that correlate with abrupt position changes
the head up position
Respiration can be made easier with:
the head down position
Cardiovascular function can be made better with:
morbid obesity
parturient
poor CV function
mediastinal mass
What types of patients do not benefit in the supine position?
done in the lightest planes possible
coordinated by anesthesia
done slow, gentle, and deliberately
use adequate padding
position patient as if awake (in a "normal" position)
maintain patient dignity
use adequate help
document properly
What are some considerations for positioning?
0.04%
Overall risk of injury d/t positioning is ____
15-16%
Incidence of perioperative nerve damage claims is about ____
brachial plexus
lumbosacral nerve root
ulnar nerve
The most frequent malposition injuries are:
neural tissue or muscular stretch
pressure
ischemia
inflammation
immunosuppression
What causes injury related to positioning?
positioning
devices for positioning
surgical duration
type of anesthetic
pt conditions
Contributors to injury include:
horizontal
contoured (lawn chair)
lithotomy
What are the types of supine positions?
some flexion of the neck
pillow under knees
no stretch of the arms
pressure points padded
Describe the optimal supine position.
pt is positioned while awake
minimal physiologic insult
no skin contact with metal
easy access to arms, eyes, mouth
What are some advantages of the supine position?
May not be tolerable for the obese, those with mediastinal masses, poor cardiac function, and the parturients.
What are some disadvantages of the supine position?
neuropathies
backache
ischemic and pressure injuries (including compartment syndrome)
crush injuries
paraplegia
inappropriate use of pads and support devices
What are potential complications of the supine position?
it is very superficial and runs along the medial epicondyle
injury risk is increased with hypotension and hypo perfusion
Why is the ulnar nerve prone to injury?
keep the elbow neutral and pad it
How do you prevent ulnar nerve injury?
avoid shoulder compression
avoid head rotation away from abducted arm
How do you prevent injury to the brachial plexus?
check the IV remains patent
PNS use will be limited
additional padding is controversial
palms should be facing outer thigh "at attention"
What should you consider if the arms need to be tucked?
standard
low
high
exaggerated
What are the lithotomy variations?
GU
GYN
Colorectal
Lithotomy is most often used for what types of procedures?
maintains access to head/airway
access to arms
increases circulating blood volume and preload (d/t legs being elevated)
What are advantages of lithotomy?
multiple opportunities for injury (rotation of hips, brachial plexus, increased surgery time)
decreases VC/FRC (with elevation of the legs)
lowering legs produces hypotension
pts are prone to backache
increases aspiration risk
What are disadvantages of lithotomy?
crush injuries (during bed manipulation)
neuropathies
musculoskeletal strain
ischemia (and compartment syndrome)
What are potential complications of lithotomy?
2mmHg
There is a ___ drop in MAP for every inch a limb is above the atrium.
common peroneal nerve (can be compressed by candy canes)
femoral and obturator nerves (with >90 degree flexion of the thigh)
sciatic nerve (is knee is extended and hip flexed)
What nerves are at risk for damage in lithotomy?
standard
semisupine and semiprone
flexed lateral (jack knife)
What are the variations of the lateral position?
head support
axillary rolls (do not go in the axilla)
pillows between arms and legs
maintain body alignment (avoiding forward pelvic tilt)
When using the lateral decubitus position consider:
FRC is decreased more than in supine
increased risk of atelectasis (dependent)
gravity will increase perfusion to the dependent lung
V/Q mismatch
slowly change positions to decrease hypotensive episodes
difficult re-intubation
monitoring challenges (BP cuff, arterial line, ECG leads)
dependent ear and eye injuries
What are disadvantages of the lateral position?
the mediastinum shifts to the dependent hemithorax
there is longitudinal axis cardiac rotation (that impairs venous return and decreases CO)
What are some pathophysiology considerations for the lateral position?
Flexed Lateral/Kidney position
flexion of the spine to separate iliac crest and rib cage
upper leg straight, lower flexed
lower table is flexed and kidney rest at iliac crest
try to avoid compression of inferior vena cava and ribs
lateral jackknife position
Lateral decubitus + table bend
moves the superior iliac crest towards the feet and opens the kidney space
ischemic injuries (to ears/eyes)
muscular and ligament injuries (to neck)
neuropathies (suprascapular nerve, long thoracic nerve, radial)
What are potential complications of lateral position?
contoured or lawn chair position
dorsal recumbent
the table is flexed under lumbar area
pad under head
distal flexion under knees
leg straps are above knees
arms abducted less than 90 degrees or tucked
sitting
supine- tilted head up
lateral- tilted head up
prone- tilted head up
What are the variations of contoured or lawn chair?
decreases bleeding
improves surgical field (keeps it above the RA, less bleeding, better visual)
good for shoulder procedures
good for posterior fossa craniotomy
What are advantages of sitting beach chair?
sitting/beach chair
Pt is positioned over break in the table
footboard is perpendicular
back rest is elevated (45-75 degrees)
knees are flexed
arms on lap pillow
head can be difficult to position
improves ventilation (VC, FRC, and diaphragm movement)
easy access to ETT and head
decreases facial swelling
What are some advantages of sitting position?
ETT can migrate inwards
decreased venous return = decreased CO and SV 12-20% and decreased MAP and CPP 15%
increased risk for venous air embolism
takes a team to get them in position
What are some disadvantages of sitting position?
head is elevated above heart causing postural hypotension
blindness
neuropathies (mid-cervical tetraplegia, sciatic)
air embolism (pneumocephalus, VAE)
What are some potential complications of sitting position?
peripheral vasodilation causes decreased CO, baroreceptor reflex increase in HR and SVR
CBF will fall momentarily
protect ulnar and peroneal nerves
prevent cervical vein obstruction (keep the neck flexed)
What is important to remember about sitting position?
Venous air embolism
associated with sitting position (ANY time the surgical site is above the right atria and is exposed to room air)
can cause CV collapse or stroke
>300ml of air is lethal
transesophageal echocardiography (TEE) is gold standard
transthoracic doppler
ETCO2 drop
heart dysrhythmias
ET nitrogen concentration will go up
esophageal stethoscope will have "millwheel murmer"
How can you detect a venous air embolism?
left lateral decubitus and reverse Trendelenburg
aspiration of volume of air from right atrium
How do you treat a venous air embolism?
full prone
prone jackknife
prone kneeling
What are the variations of prone position?
prone position
face, chest, abdomen, and thigh, knees, toes, and parts of forearms contact the bed
used for rectal, back, and spine surgery
requires a coordinated, difficult turn
has lots of impact on CV function, not so much on respiratory
pt is induced with spine on the gurney
disconnect as many monitors as possible prior to turn
place IV and A-lines over the patient during the turn
prevent excessive cervical spine extension or flexion
place arms at sides or above head w/ forearm ventral to horizontal torso axis
avoid extreme abdominal pressure
protect abdomen, breasts, and genitalia
What are important things to remember with prone positioning?
assure eyes and ears are free of pressure
arms abducted less than 90 degrees or tucked
support chest and hips and the abdomen hangs free
protect the ETT
pad knees carefully in kneeling or leaning
Things to consider with prone positioning?
causes a restrictive airway pattern (increases PIP)
obese pts may require special positioning
hypotension is common after repositioning
ETT complications (difficult to reintubate)
multiple opportunities for injury (especially brachial plexus)
neck/shoulder pain is common
needs a whole team to reposition
What are prone disadvantages?
eyes and ears
blindness
neck issues
brachial plexus
breast injuries
abdominal compression
stoma and genitals
extubation (have a plan)
What are potential complications of prone positioning?
impingement or traction of nerve roots
sternal retraction causing impingement between clavicle and first rib
traction of long thoracic nerve
traction of supraclavicular nerve
traction or compression of brachial plexus by head of humerus in abduction
axillary nerve compression against humerus
radial nerve compression against humerus
median nerve dysfunction
ulnar neuropathy
What are potential brachial plexus injuries?
limit abduction of arms to less than 90 degrees
avoid rotation and lateral flexion of the head
avoid steep Trendelenburg and shoulder braces
put shoulder braces only over the acromioclavicular joint with arms tucked
avoid extension of the arm posterior to plane of the torso
support arms in the seated position
How to prevent brachial plexus injury?
Trendelenburg position
head down, knees flexed
start w/ 10-15 degrees
steep only for short periods
useful for hypotension and GYN/lower abdomen surgery
CV, respiratory, ICP
Head-down positions cause pronounced ____, ____, and ____ impacts
exposure for lower abdominal surgery
access to head and arms
decreased risk of aspiration (but increases risk of vomitting)
increases venous return (transiently)
What are advantages of Trendelenburg?
Decreases FRC
causes higher inspiratory pressures
decreases pulmonary compliance
increases work of breathing
increases venous return
causes a cephalad shift of the mediastinum
What are disadvantages of Trendelenburg?
ETT displacement
atelectasis
face and airway swelling
cardiac pts may not tolerate
head and neck injury
increased CSF and ICP
shoulder braces can compress SC neurovascular bundle b/t the clavicle and 1st rib
eye damage (glaucoma)
What are potential complications of Trendelenburg?
perioperative visual injury
3.3% of AANA closed claims injuries
can include: corneal abrasions, ischemic optic neuropathy, edema, retinal detachment, ocular hemorrhage, vitreous loss, central retinal artery occlusion
pressure on the eye
hypo perfusion
ischemic optic neuropathy (from decreased perfusion, increased IOP, and decreased choroidal perfusion)
retinal artery or vein occlusion
glycine toxicity
What are mechanisms of PVI/ION?
position (prone, lateral, and Trendelenburg)
hypo perfusion (hypotension, large blood loss, low hgb)
anemia
long spinal surgery
male patients
What are risk factors for PVI/ION?
maintain adequate oxygenation and perfusion
avoid pressure on the globe
avoid over administration of crystalloid solutions
How can you prevent PVI/ION?
Homeothermic
able to control own body temperature
Poikilothermic
body temperature matches the temperature of their environment
Hypothermia
low body temperature (core temp less than 36 degrees)
Hyperthermia
high body temperature (core temp greater than 37 degrees)
fever
a rise in the temperature of the body used to fight infection
around 37 degrees (98.6)
What is the normal temp range?
warmer
Core temp is ____ than the limbs.
2-4 degrees
Core is usually ____ degrees warmer than the limbs.
over the course of a day
women around their menstrual cycle
peaks around 6pm and lowers during sleep
What things can cause temperature to flux?
the hypothalamus with the aid of thermoreceptors (peripheral and central)
What mediates our temperature?
Interthreshold range
range of core temperatures where no physiological responses are evoked
41 degrees
34 degrees
A core temp of more than ___ or less than ____ demonstrates impaired thermoregulation.
there is a poor environmental response to temperature extremes
decreased shivering
slower metabolic rate and sedentary lifestyle
decreased vasoconstriction/vasodilation
less or absent sweating
decreased perception of heat and cold
the thermoregulatory threshold is reduced an addition degree C
How does thermoregulation change with age?
infants produce heat through brown fat metabolism (non-shivering)
ineffective heat conservation (due to greater BSA)
thin subQ fat layer
What is different with infants and thermoregulation?
BSA:BWT ratio is greater
lower sweating rate
greater vasodilation and vasoconstriction
What is different with children and thermoregulation?
radiation (60%)- through electromagnetic waves
convection (30%)- warm air near the body is replaced by cold air
conduction (negligible)- direct contact
evaporation (10%)- breathing and sweating or through open surgical wounds
How do we lose heat?
they prohibit behavioral responses
they cause vasodilation, and inhibit vasoconstriction
they impair normal autonomic thermoregulatory control
the inter-threshold range is increased (dose dependently) from 0.2-0.4 to 2-4 degrees C
How does GA change the way the pt thermoregulates?
hypothermia
What is the most common thermal disturbance during GA?
anesthetic-impaired thermoregulation
exposure to a cold OR
administration of cool fluids
heat transfer
massive blood loss
What can cause hypothermia during GA?
redistributed
Normally the periphery is 2-4 degrees cooler than the core but during anesthesia there is vasodilation and the heat is ____
decrease vasoconstriction and shivering thresholds about 0.6 degrees C above the level of the block
below the level of the block, there is vasoconstriction
overall decrease in intensity and gain of shivering
the thermal input is blocked (vasoconstriction/shivering thresholds reduced, decreased perception, behavioral regulation impaired)
How do epidurals/spinals alter thermoregulation?
core temp drop 0.5-1 degree C
d/t core to periphery redistribution
heat loss exceeds metabolic heat production
temp loss may not plateau
How does hypothermia occur under regional anesthesia?
1 degree C
Combined GA and neuraxial anesthesia will decrease the temperature threshold an additional ____
impaired coagulation
prolonged emergence
increased risk of wound infection
decreased thermal comfort
3X increase in morbid myocardial outcomes
What are the adverse effects of mild hypothermia?
40%
increases O2 consumption
increases IOP and ICP
increases metabolic demand
aggravates wound pain
How common is post anesthetic shivering? and what are the adverse effects?
pre-warm the pt
use active warming post-operatively
decrease shivering threshold (with clonidine or dexmedetomidine)
treat active shivering with meperidine 12.5-25mg
How to treat shivering?
Early: tachycardia, hypertension, increased CO, vasoconstriction
Late: bradycardia, decreased CO, hypotension
ECG: slow conduction, bradycardia, T-wave inversion, Q-T prolongation, ventricular ectopy
What are the cardiovascular effects of severe hypothermia?
early: increased RR
late: reduced RR and TV, diminished hypoxic pulmonary vasoconstriction and responsiveness to hypoxemia and hypercarbia, diminished muco-ciliary activity
What are the respiratory effects of severe hypothermia?
Early: hemoconcentration, increased viscosity, decreased oxygen availability (left shift)
Late: DIC, thrombocytopenia
What are the hematologic effects of severe hypothermia?
Early: hyponatremia, hyperkalemia, hyperglycemia
Late: metabolic acidosis (ischemic)
What are the metabolic effects of severe hypothermia?
CBF decrease 6-7% per 1 degree C in temp
(34 amnesia, 30 obtundation, 26 loss of pupillary reflex, 18 loss of brain activity)
What are the neurologic effects of severe hypothermia?
Early: decreased motility, diminished hepatic clearance
Late: ulcers in stomach, ileum, and colon and hemorrhagic pancreatitis
What are the GI effects of severe hypothermia?
Early: "cold" diuresis d/t central blood volume increase and impaired renal tubular sodium reabsorption
Late: oliguria and axotemia
What are the renal effects of severe hypothermia?
cerebral ischemia and hypoxia protection
improves outcomes in cardiac arrest
decreased MH incidence/reaction
What are some benefits of mild hypothermia?
excessive heating (treat by D/C active warming)
greater risk in infants and children
fever (d/t allergy, infection, wrong blood given, or during epidural analgesia)
What can cause intraoperative hyperthermia?
Stroke
neuroleptic malignant syndrome
malignant hyperthermia
Zebra causes of intraoperative hyperthermia?
treat underlying cause
administer antipyretic medication
active cooling
How to treat hyperthermia?
monitor and record core body temp in GA is surgery is longer than 30 minutes
or with major surgery with neuraxial anesthesia
maintain core temp greater than 36 degrees C (unless otherwise indicated)
What are the temperature monitoring guidelines?
pre-warm the patient (in the holding area)
use passive insulation
increase ambient room temperature (especially for pediatrics)
Use forced air blankets (most effective)
use warm IV fluids
use low-flows w/ HME on the circuit
use warm prep solutions
How can we prevent hypothermia?
nasopharyngeal, esophageal, and tympanic
What are the "true core temp" sites?
spinal
Core temperatures re-warm faster in ____ over general anesthetic
vasodilated
vasoconstricted
It is easier to keep a pt warm when they are ____ than to try to re-warm them when ____
it occurs when an anesthesia provider is involved and the pt is still capable of purposeful responses.
What is monitored anesthesia care (MAC)?
When the pt is incapable of purposeful responses.
When does MAC become GA?
When the anesthesia provider is not involved.
When is MAC actually conscious/moderate sedation?
pt comfort, safety, satisfaction
What are the care goals of MAC?
cognitive ability
respiratory status
cardiac function
presence/loss of protective reflexes and purposeful responses
Sedation provides a continuum progressive changes in:
Minimal sedation (anxiolysis)
pt's cognitive and coordination is affected
response to verbal commands, airway, respiratory function, and (usually) CV function is unaffected
moderate sedation/analgesia
medication induced depression of consciousness
vast majority of body functions unaffected except for consciousness
Deep sedation/analgesia
NOT the goal of conscious sedation
required qualified anesthesia provider
consciousness and responsiveness is affected and some degree of CV, airway, and respiratory function
General Anesthesia (GA)
medication induced loss of consciousness
ALL body functions affected
sufficient staff with the proper training
What doe the JC mandate for sedations?
ASA and AANA joint statement
What provides guidelines for RNs/non-anesthesia providers that administer sedation
monitor VS
be prepared to administer anesthetics
be prepared to provide medical care
What is the anesthesia provider's role with MAC?
consent for sedation and analgesia
two pt exams documented
full preoperative evaluation
What are the patient requirements for MAC?
head to toe assessment
previous anesthetic complications
current medications
drug allergies
history of drug/alcohol/tobacco use
last oral intake
pt ability to cooperate
What are the TJC documentation standards for MAC?
everything you would have available in the OR to switch to GA if indicated
What equipment do you want to have available if doing MAC?
pulse ox
NIBP
EKG
capnography
What are the required monitors for MAC?
procedure time less than 2 hours
minimal risk of bleeding
low incidence of post op pain
surgeon has to be on board
the pt must be cooperative
What type of scenario makes a good MAC case?
ones that have supplemental blocks- eyes, dental, vascular, ortho, GYN, urology
ones with low stimulus, short duration, cooperative pt, reasonable for the pt to tolerate
What types of procedures make good MAC cases?
inadequate/excessive local
painful/difficult position
uncooperative patient
inappropriate situation for the pt
paradoxical effects from sedation
What is the recipe for a failed MAC?
respiratory depression
hypoxemia/hypercarbia
broncho/laryngospasm
upper airway obstruction
N/V
bradycardia/tachycardia
hyper/hypotension
myocardial ischemia
CHF
CV collapse
allergic rxn
What are potential complications during MAC?
multiple meds, given fast
extremes of age
morbid obesity
disease states
CV/respiratory/GI/metabolic/hepatic/renal/hematological/neurological derangements
What increases the risk of complications with MAC?
oxygen
N2O
hypnotics (propofol/ketamine)
benzodiazepines
alpha 2 agonists
narcotics/opioids
What medications are used for MAC?
you can take them to fast track (not PACU)
What is Dr. Benhem's gauge for it was a good MAC case?
same standards of care
goal is to be well equipped, familiar, and safe
What are the general principles of remote anesthesia care?
oxygen
suction, scavenging system
equipment, drug, monitors
electrical outlets
illumination
space
emergency equipment
communication
building and safety codes
What are the common themes of standards of care?
physical layout too small
outdated/non functional equipment
untrained personnel
far from additional help
accessibility to the patient/equipment
disparate emergency response
What are some common problems doing anesthesia outside of the OR?
no piped-in gas or suction
no scavenging capability
lack of three pronged outlets
lack of emergency equipment/knowledge of location
anesthesia drugs/supplies
patient transport/proximity of recovery
What problems could set you up for failure outside of the OR?
short-acting agents
quick re-distribution and elimination
reversible
small side-effect profile
What are the best characteristics for medications used outside of the OR?
cardioversion
AICD/pacemaker placement
percutaneous coronary intervention
radiofrequency catheter ablation
colonoscopy/esophagogastroduodenoscopy (EGD)
endoscopic retrograde cholangiopancreatography (ERCP)
bronchoscopy
interventional radiology/fluoroscopy
electroconvulsive therapy
extracorporeal shockwave lithotripsy (ESWL)
What are some common procedures where we do anesthesia outside of the OR?
sternal d-fib pads
During AICD placement, make sure you have ____ placed on the pt.
25% increase in serum creatinine (SCr) from baseline
or a 0.5 mg/dL (44 µmol/L) increase in absolute SCr value—within 48-72 hours after intravenous contrast administration.
How to diagnose contrast induced nephropathy?
prior reaction
allergy to shell fish or seafood
beta blocker use
interleukin-2 use
asthma
What risk factors can a pt have to increase their chances of adverse contrast reaction?
pre treat pt with 40mg prednisone, 50mg Benadryl, 20mg Pepcid
If someone has had a previous contrast reaction, what should you do?
exaggerated sympathetic responses to indirect acting sympathomimetics and prolonged NMB effects
(Demerol is contraindicated)
What will we see with a pt on MAOIs?
prolonged NMB effects
What will we see with a pt on lithium?
exaggerated sympathetic responses to direct acting sympathomimetics and increased effects of anticholingergic drugs
What will we see with pts on tricyclic antidepressants?
pheochromocytoma
recent MI (less than 3 months)
What are absolute contraindications to ECT therapy?
increased ICP or recent CVA (less than 3 months)
CV conduction defects
high risk pregnancy
cerebral/aortic aneurysm
What are relative contraindications to ECT?
pregnancy
coagulation abnormalities
unclear path to stone
morbid obesity
What are the contraindications to ESWL?
gated ESWL
uses R wave of ECG to fire shockwave
less ectopy
takes more time
un-gated ESWL
random firing
move likely to have PVC's/PAC's
shorter procedure time
Supine
What position is this?
Contoured Supine
What position is this?
Standard Lithotomy
What position is this?
Low Lithotomy
What position is this?
Exaggerated lithotomy
What position is this?
High lithotomy
What position is this?
Hemilithotomy
What position is this?
lateral decubitus
What position is this?
flexed lateral position
What position is this?
lateral jackknife position
What position is this?
Sitting position
What position is this?
Beach chair position
What position is this?
Prone position
What position is this?
prone jackknife position
What position is this?
prone kneeling
What position is this?
Trendelenburg position
What position is this?
Reverse Trendelenburg
What position is this?
Impingement or traction of nerve roots
What injury is associated with number 1?
Impingement of brachial plexus between clavicle and first rib
What injury is associated with number 2?
Traction of supraclavicular nerve
What injury is associated with number 3?
Traction of long thoracic nerve
What injury is associated with number 4?
Traction or compression of brachial plexus by head of humerus in abduction
What injury is associated with number 5?
Compression of axillary nerve against humerus
What injury is associated with number 6?
Compression of radial nerve against humerus
What injury is associated with number 7?
less invasive surgical procedures
decreased morbidity
decreased pain
Ambulatory surgery has increased due to:
saves money
less pre-op eval, less post-op meds
low morbidity and mortality
patient preference
more flexible scheduling
lack of dependence on hospital bed availability
lower incidence of infection
lower incidence of respiratory problems
shorter surgical waiting lists
What are the advantages of ambulatory surgery?
"not sick" patients, will return to "normal life" after
patient-focused/patient selection
must be medically and psychologically stable
pt must be willing and able to participate in their own care at home
patient education/expectation management
What are the guiding principles of ambulatory surgery?
irretractable PONV
irretractable pain
What are the two biggest reasons pts fail to ambulatory discharge?
Hospital integrated
Hospital dedicated
Freestanding
Hospital connected
What are the 4 types of ambulatory surgery facilities design?
Hospital intergrated
Facilities design where ambulatory pts are admitted through separate area of the hospital, but surgeries take place in the some ORs as inpatients
Hospital dedicated
Facilities design where the hospital has ORs dedicated to outpatient and the staff and ORs are separately managed
freestanding attached
Facilities design where the facility has a completely separate admission, OR, PACU, and D/C areas but still found within a hospital with inpatient capabilities
freestanding isolated
Facilities design where the facility is completely separated physically from a hospital with inpatient capabilities
The classification system
JC for ambulatory
more loose for office-based
What is the major difference between ambulatory surgical centers and office-based surgical practice?
Level 1- minor procedures requiring topical or local and minimal oral sedation
Level 2- Oral or IV sedation
Level 3- Major conduction block required, GA, or deep sedation
What are the three levels of ambulatory/outpatient surgery?
there will be minimal postoperative physiologic disturbances
risks of pre-existing medical condition is well controlled
uncomplicated, short recovery anticipated
What is the best type of patient for outpatient surgery?
CAD- with new or escalating symptoms
CHF- unless cardiac eval documents prove it is resolved
aortic valve stenosis- if <1cmsquared valve area and diagnosis confirms severely stenotic lesion
BEWARE pts with ____ when considering outpatient surgery?
pt related- age, chronic diseases, function status, medical therapy, implantable devices, and previous surgeries
surgery related- type of surgery (vascular, endoscopic, abdominal), urgency of surgery, duration, blood loss
test related- sensitivity and specificity of a test, effect on management
Cardiac risk factors to consider with ambulatory surgery?
Major predictors- unstable, decompensated, severe
Intermediate predictors- mild angina, previous MI
Minor predictors- abnormal EKG, A-fib, HTN
How are the levels for the ACC/AHA cardiac risk factors separated?
Ashtma
wheezing that clears with routine management
COPD if well compensated
URI in the last 2-4 weeks but after symptoms are gone
What respiratory imbalances will not exclude a pt from outpatient surgery?
Nope- but anticipate undiagnosed OSA
Is obesity an exclusion criteria for ambulatory surgery?
cardiopulmonary disease
OSA
metabolic, hormonal, physiologic problems
post-op hypoxemia
difficult airway/decreased FRC
Those who are severely obese are more at risk for?
generally considered low-risk but it is advised they are observed for 4 hours after surgery
How does a history of malignant hyperthermia change pt criteria for ambulatory surgery?
risks are increased if poorly controlled (AIC >8.6)
consider facility policies about DM medications (usually hold for 2 days)
include additional testing pre-operatively
The perioperative hypoglycemia "alert value" is <70
How does a history of diabetes mellitus change pt criteria for ambulatory surgery?
if they have a history of apnea
if they had a sibling die of SIDS
if they have a history of anemia
if they were born premature (<37 weeks) who are younger than 50-55 weeks post-conceptual age
probably best to admit all infants younger than 60 weeks post-conceptual age
What type of pediatric populations have increased ambulatory surgery risk?
postoperative delirium
What is the geriatric population more at risk for with ambulatory surgery?
what is their physiologic age
can their care provider take care of them
patient medications and can the care taker keep track
What should we consider with the elderly population and ambulatory surgery?
complex medical problems
life-threatening chronic illness
obesity or morbid obesity complicated by symptomatic CV or respiratory problems
multiple chronic centrally active drug therapies
MOA inhibitors, active/chronic cocaine abuse
lack of care taker
barracks dwellers
the elderly
ex-premature infants
pts requiring blood transfusions
CHF, CAD, Aortic valve stenosis, COPD, asthma (with poor control)
What type of patient is probably inappropriate for ambulatory services?
muscarinic (treat with atropine or glycopyrrolate)
dopaminergic (treat with droperidol)
histaminergic (treat with promethazine)
serotonergic (treat with ondansetron)
opioid and neurokinin (treat with aprepitant)
What are the 5 receptors involved with PONV?
urinary retention
sore throat
post intubation stridor
postoperative HTN
syncope
headache
social
What are some postoperative considerations for pts in ambulatory surgery?
deliver a stable pt
maintain responsibility of the airway, hemodynamic stability, pain, nausea
communicated relevant information to PACU nurse
What are the roles and responsibilities of the anesthesia provider in the PACU?
co-morbidities
type and length of surgical procedure
type of anesthetic
What determines the level of PACU care required?
Phase I of PACU
requiring more intense recovery needs
requires one-on-one care/monitoring and constant vigilance
Phase II of PACU
can follow phase I or can start here as "fast track"
less intensive and requires less care/monitoring
pts leave OR "awake"
care is focused on preparation for discharge
Phase III of PACU
occurs in the same physical location, pts have met criteria to leave phase I but are unable to go to another location
fast-tracking
the process of admitting patients from the OR directly to phase II
those with MAC or light sedation
superficial and peripheral procedures
cases done under local or regional anesthesia
What types of cases can be fast-tracked?
patient identification confirmed
procedure performed
type of anesthetic
medications used/ if they were reversed
antibiotics, dose, time
IV access
I&Os (EBL, urine, IVF)
areas of concern
What should be included in the PACU report?
compromised oxygenation and ventilation
hypertension or hypotension
tachycardia or bradycardia
hypovolemia
pain
residual weakness
nausea and vomiting
agitation/combativeness/delirium
What are common post-operative complications in the PACU?
prevent by ensuring pt is managing airway prior to leaving OR
reverse narcotic if needed
use adjuncts if necessary
stimulate the pt, jaw thrust, reposition
be prepared to reintubate
How should you treat compromised ventilation and oxygenation in the PACU?
100% oxygen
jaw thrust with Larson maneuver
manual CPAP
succinylcholine (0.25-1mg/kg IV)
propofol (sub induction dose)
attempted intubations
cricothyrotomy/jet ventilation
How do you treat laryngospasm?
manage pharmacologically as needed
rule out hypoxia, hypercapnia, and metabolic derangements
treat pain
How do you treat hypertension?
give a 250-500 ml crystalloid bolus
give a vasopressor
initiate treatment for allergic reaction if suspected
notify primary provider/surgeon/cardiology
How do you treat hypotension?
treat the cause
give ephedrine or glycopyrrolate
How to treat bradycardia?
treat with short acting drugs
use strict rate-control in cardiac patients at risk for MI
How to treat tachycardia?
abdomen-hypoventilation-atelectasis-hypoxemia-pneumonia
limbs-DVT
pain in general-catecholamine release-tachycardia/HTN-MI
What are the cascade effects of poorly managed pain?
Pre-treat with PO/IV Tylenol
consider procedure specific needs
titrate opioids
balance short and long acting opioids
consider NSAIDS, Tylenol, ketamine, steroids, LA
consider opioid tolerant individuals
How to manage post operative pain?
Treat by hitting all 5 receptor types
maybe use TIVA with propofol instead of GA
consider propofol and steroids
How can you prevent PONV?
Scopolamine- anticholinergic
Promethazine- phenothiazine
Ondansetron- serotonin receptor antagonsit
Dexamethasone- corticosteroid
What are the commonly used antiemetics?
protect the pt, ensure ventilation and oxygenation
prevent harm
rule out hypoxia
check for residual weakness
manage pain
careful use of propofol, dexmedetomidine, clonidine can help smooth emergence
talk to the patient and try to orient them
What to do for postoperative agitation/combiteness/delirium?
meperidine 25-50mg IV
How to treat postoperative shivering?
be careful with benzodiazepines
do not extubate until they are awake
they might need to stay overnight
use their own CPAP machine
better to use short acting opioids/anesthetics
regional might be a good choice
What to do for patients with known OSA?
Modified Aldrete Score
Respiration
O2 saturation
Consciousness
Circulation
Activity
Vital signs
N/V
Pain
Bleeding
What is included in PACU discharge criteria?
Documented post-procedure
should be conducted by anesthesia after pt is fully recovered
try to follow up on your own patients
focus on anesthesia type complications
What are the requirements of the post anesthesia follow up evaluation?
ensure patency of airway and adequate oxygenation/ventilation
be sure you can assess respiratory status during transfers and that you have the right equipment to intervene
maintain IV access
consider having a parent present if you can
ensure one on one care and suction
communicate with the parents
What are some considerations specific for pediatric pts in the PACU?
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