2.3 Anesthesia In Outpatient & Surgical Centers

Front 1

What caused the transition to increased use of outpatient surgery?

(70% of surgeries are ambulatory)
(increase occurred withing last 3 decades)

Back 1

Changing role of anesthesia provider
Availability of highly titratable anesthetics
Less invasive surgical techniques
Faster recoveries
Rapid, short-acting drugs
Cost savings
Reimbursement

Front 2

What types of facilities can provide outpatient and OBA surgery?

Back 2

Hospital-based
(Inpatient & Outpatient)
Surgery Center
Short daytime stays
Some have overnight facilities
Office-based

Front 3

What percentage of Outpatient procedures are done office based (OBA)

Back 3

15-20% of all outpatient procedures done OBA

Front 4

Why might using hospital based anesthesia be preferred?

Back 4

Offers greater resources
Access to specialists
Ease of transfer
Wider range of services (lab, xray…)

Front 5

Hospital based anesthesia (outpatient)

Back 5

1)May be integrated with the main OR suite
2) May be on same campus
3.) May be affiliated with hospital at a different location

Front 6

What types of procedures & what rate performed in Outpatient centers?

Back 6

3 decades of exponential growth.
Simple procedures (CXR) to broad spectrum surgeries w/ inc. complex comorbidities (w/n hospital, freestanding surgery centers & physicians offices)

>70% all Sx performed on ambulatory basis

Front 7

The evolution has occurred b/c of what?

Back 7

Changing role of Anesthesia provider.
Availability of highly titratable anesthetics.
Less invasive surgical techniques.
Faster recover (rapid, short-acting drugs)
Cost savings.
Reimbursement

Front 8

What are three typed of facilities?

Back 8

Hospital-based (In pt/Out pt)
Surgery Center (short daytime stay, some overnight facilities)
Office-based (15-20% out pt procedure this way)

Front 9

Hospital-based centers may be located where?

Back 9

Integrated w/ the main OR suite.
On the same campus.
Affiliated w/ hosp at different location (specialists, ease of transfer, wider range of services like labs & xray)

Front 10

List 6 different things about surgery centers.

Back 10

No hospital affiliation.
Physician owned.
Surgeon usually has admitting privileges at nearby hospital.
Focused towards pt comfort & satisfaction (parking, setting)
More privacy
Geared towards daytime stays, but may have overnight beds)

Front 11

List some aspects of Surgery Centers?
ownership
focus

Back 11

Often physician owned
Surgeon usually has admitting privileges at a nearby hospital
Focused toward patient comfort and satisfaction (parking, setting)
Offers more privacy
Geared toward daytime stays, but may have ability for overnight

Front 12

Surgury centers usually do not have _______?
But the physician do have ______?

Back 12

no hospital affiliation

admitting privileges at nearby hospitals

Front 13

OBA (Office-based Anesthesia)
can be associated with what Care providers?

Back 13

Physician, dentist, podiatrist

often attractive to CRNA's with many years of experience wanting a schedule change

Front 14

Name 2 pros of office based anesthesia?

Back 14

less costly & more privacy

Front 15

What 2 states have been at the forefront of regulating office based anesthesia?

Back 15

Florida
New York

Front 16

Florida BOM new standards include

Back 16

Limits on types and length of procedure ( 8 hours)

Accrediting office facilities

Credentialing surgeons

Determining level of training for anesthesia personnel

Mandatory reporting of adverse incidents

Front 17

as a result of 6 deaths in 5 months what did Florida BOM do?

Back 17

August 2000 issued a 90 day moratorium on level III surgery
General anesthesia, major conduction anesthesia (regional), deep sedation

Front 18

The Moratorium in Florida was lifted when what restrictions were put in place?

Back 18

Moratorium lifted after following restrictions in place:
Prohibited Level III surgery for high risk (ASA 3) patients
Prohibited combination of liposuction and abdominoplasty
Limited length to 8 hours
Required reporting of all surgical procedures
Presence of MDA for all level II surgeries

Front 19

what is an Office adverse event?

These are a matter of public record

Back 19

An event over which physician could exercise control, associated in whole or in part with a medical intervention and results in patient death, injury, or any condition requiring transfer of patient to a hospital

Front 20

What type of adverse event are records private and confidential – not a matter of public record?

Back 20

a ASC is required to report adverse incidents which include: death, brain/spinal damage, wrong procedure and surgical repair of unexpected complication.

Front 21

Retrospective 2 year study of procedures in offices and ASC’s in Florida

Back 21

Despite changes to improve safety, data suggests that adverse incidents and deaths are 10 times more likely to occur in an office than an ASC in Florida.

Front 22

What are some Current concerns in the field of OBA?

Back 22

What does OBA consist of – GA with TIVA, regional, conscious sedation or local infiltration?

Do the qualifications of anesthesia providers influence the concept?

What is concern level for dental anesthesia?

Front 23

Adverse Events New York?

Back 23

tumescent liposuction due to toxic levels of local anesthetic (> 65 mg/kg)

Front 24

What is a major hindrance to the accuracy of adverse events in closed claim database?

Back 24

Five year time lag before adverse event is included in the closed claims data base – therefore recent increases in OBA will not be evident for several years.

Front 25

Who are the practitioners of scary adverse event anesthesia rt NY case studies?

Back 25

In 1997, non-plastic surgeons performed 50% of 250,000 liposuctions
Dermatologists, primary care MD’s, emergency MD’s, even unlicensed providers
Cosmetologists
Some representing “board certification” after only a week’s training

Front 26

Office-based Anesthesia (OBA) is associated with what?

What are pros/cons with them?

Back 26

Physician, Dentist or Podiatrist (2003: 1.2 million OBA performed)

More privacy, less costly
Lack of regulation (wild, wild west of health care)

Front 27

What state BOM instituted a standard of care for OBA procedures in 1994? What ocured in the following 5 years?

Back 27

Florida.

Large # of deaths in 5 years,
March 2000 - issued new standards.

Front 28

What did Florida BOM new standards include?

Back 28

Limits on types & length of procedure
Accrediting office facilities
Credentialing surgeons
Determining level of training for anesthesia personnel
Mandatory reporting of adverse incidents

Front 29

After Florida BOMs new standards were implemented, what happened?

Back 29

6 more deaths in 5 months occurred, & August 2000 they issued a 90 day moratorium on Level III surgery (GA, Major conduction anesthesia (regional) Deep sedation)

Front 30

Lifted moratorium when what restrictions were in place?

Back 30

Prohibitied Level III surgeries for high risk (ASA 3) pts
Prohibited combination of liposuction & abdominoplasty
Limited length to 8 hrs
Required reporting of all surgical procedures
Presence of MDA for all level II surgeries

Front 31

What is, an event over which physician could exercise control, associated in whole or in part w/ a medical intervention & results in pt death, injury or any thing requiring transfer to a hospital?

Back 31

Office adverse event
(These are a matter of public record)

Front 32

Current literature data suggests that despite changes to improve safety, adverse incidents & death are?
(physician office vs Ambulatory Surgery Center)

Back 32

10 times more likely to occur in an office than an ASC in Florida
(retrospective 2 year study of offices & ASCs procedures)

Front 33

What are some current concerns?

Back 33

What does OBA consist of? (GA w/ TIVA, regional, conscious sedation, local infiltration)
Qualifications of anesthesia providers influence the concept?
Concern level for dental anesthesia

Front 34

What are some adverse events that occured in NY (1993-1998)?

Back 34

5 deaths assoc. w/ tumescent liposuction d/t toxic levels of local anesthetic (>65 mg/kg) "mixed w/ injection to liquify fat"

Front 35

What are other complications that can occure w/ liposuction?

Back 35

Pulmonary emboli, Pulmonary Edema, Fat Emboli, CHF, Necrotizing fasciitis, Organ perforation

Front 36

Major factors in the adverse events?

Back 36

over dose of pain meds..and the patient was home alone unattended

Front 37

Standards for OBA Practice
AANA

Back 37

1)Perform a thorough and complete preanesthesia assessment
2)Obtain informed consent for planned anesthetic intervention from patient or legal guardian
3) Formulate a patient-specific plan for anesthesia care
4.)Implement and adjust the anesthesia care plan based on pt’s physiological response

Hint 37

1) ASA, airway, prev. anesth hx, allergies, NPO status, HX/physical
2.) R&B of anesthesia, consent obtained for planned surgical/diagnostic procedure
3.)Based upon assessment and anticipation of potential problems in this unique setting – clears pt for anesthetic
4) Continuously adjust and monitor pt’s response to anesthetic – ability to ventilate with + pressure and availability of emergency eqpt and drugs (including Dantrolene)

Front 38

Standards for OBA continued

Back 38

5 ) Monitor pt’s physiologic condition as appropriate for type of anesthesia and specific needs
6) Complete, accurate and timely documentation of pertinent info on pt’s medical record
7) Transfer responsibility of care to other qualified providers assuring continuity and safety
8.) Adhere to safety precautions, minimizing risk of fire, explosion, shock and eqpt malfunction – document anesthesia machine & eqpt checked
9.) Minimize risk of infection to pt and others
10) Assess anesthesia care assuring its quality and contribution to positive patient outcomes
11) Respect and maintain basic rights of patients

Hint 38

5.) Minimum monitors: Pulse oximetry, ECG, NIBP, O2 analyzer and ETCO2 with GA, body temp (pediatric), esophageal or precordial stethoscope and PNS if indicated.
6.) Plan for accurate record keeping of: informed consent, pre/post evaluations, course of anesthesia, monitoring modalities, drug (dose/waste) administration, D/C followup
7.)PACU staff appropriately trained – ACLS (min. of 1) remains in facility until all pts d/c’d.
8.) Confirmation eqpt is routinely maintained and inspected for risk of malfunction and hazards
9.) Confirm that OSHA standards are followed
10.) Document patient satisfaction and outcomes
11) Function as the patient advocate and involve patient in all aspects of their care

Front 39

What factors must be considered to determine if OBA is appropriate?

Back 39

1.) Facility resources
23 hour admission
Postoperative admission
2.) Duration of procedure
Prior guideline 2 hr length – not followed as strictly
3.) Level of postoperative care patient will need
Preexisting condition, infection

Front 40

When does post op tonsillectomy/adenoidectomy bleeding usually occur?

Back 40

usually postop bleed occurs
> 12 hrs after – 3% incidence.
.

Front 41

Tonsilectomies/adenoidectomy if allowed in OBA at all require what additional precautions?

Back 41

If allowed in ASC’s at all, usually scheduled in am for maximal observation. (Personally, discharge instructions included proceeding to ER if one developed)

Front 42

Guidelines to determine if the patient is appropriate for OBA?

( have become increasingly liberal) (name 2)

Back 42

1.) Medically stable ASA 3 and some 4’s (limited procedure and less risk to patient’s health than doing in hospital)
2.) Must be able to follow pre/postop instructions and have responsible adult at home

Front 43

The same standards apply to
PREOP evaluations
(name the

Back 43

1.) Assess appropriateness of patient/procedure for setting and determine risk
2) H&P, diagnostic tests
3.) Informed consent
4.) Preoperative instructions

Front 44

In OBA Induction General anesthesia,

What patients can receive Inhalation inductions?

Back 44

adults and pediatrics

Hint 44

age

Front 45

Why is Ketamine not recommended for General Anesthesia in OBA?

Back 45

prolonged emergence

Front 46

What factors make Propofol drug of choice in induction General anestheia OBA ?

Back 46

antiemetic
quick emergence
ideal with LMA

Front 47

What are some Intraoperative consiterations in OBA?

Back 47

-Short acting opioids and agents
-TIVA acceptable
-High dose narcotic not recommended
-NDMR use depends on length of surgery, pt’s health and cost
Succinylcholine drip might be good choice for short, profound relaxation

Front 48

What is not appropriate for Maintenance/ Intraoperative period?

Back 48

High dose opioids

Front 49

What drip could be a choice for short, profound relaxation?

Back 49

Succinylcholine

Front 50

Total IV anesthesia is _______ intraoperative?

Back 50

Appropriate

Front 51

In ASA closed claims project, how many incidents occured from 1980-1990? What did they include?

Back 51

7 incidents (5 deaths resulted)
3 dental extractions
3 cosmetics
1 laser eye
(median settlement $600K; mean pt age 44)

Front 52

Who were the practitioners in 1997?

Back 52

non-plastic surgeons did 50% of 250K liposuctions
(dermatologists, primary MDs, ER MDs, cosmetologists)
Some representing "board certification" after only a week of training

Front 53

Some victims/casualties from non-plastic surgeon practicing docs?

Back 53

27 y/o AL (resp failure post brest aug)
25 y/o FL (DCed sedated 6 hrs post augmentation; dead next AM after 1 pain med taken)
28 y/o VA (MH during aug, died after transfer to ED; no dantrolene in office)
51 y/o (penis implant & facelift 9.5 hrs - O2 tank ran dry; died at local hosp)
Femal CA (facelift; demerol given after monitor turned off)
3 y/o WV (laser removal port-wine stain; seizure & no O2 available; died)
5 kids CA (dental procedures after chloral hydrate given
50 y/o FL (resp arrest cosmetic facial surgery; anoxic brain injury; died)

Front 54

What does Standard 1 for OBA practice state?

Back 54

Perform a thourough & complete preanesthesia assessment

Front 55

What does Standard 2 for OBA practice state?

Back 55

Obtain informed conscent for planned anesthetic intervention from patient or legal guardian.

Front 56

What does Standard 3 for OBA practice state?

Back 56

Formulate a patient-specific plan for anesthesia care.

Front 57

What does Standard 4 for OBA practice state?

Back 57

Implement & adjust the anesthesia care plan based on pts physiological response.

Front 58

What does Standard 5 for OBA practice state?

Back 58

Monitor pts physiologic condition as appropriate for type of anesthesia & specific needs.

Front 59

What does Standard 6 for OBA practice state?

Back 59

Complete, accurate & timely documentation of pertinent info on pts medical record.

Front 60

What does Standard 7 for OBA practice state?

Back 60

Transfer responsibility of care to other qualified providers assuring continuity & safety.

Front 61

What are 3 advantages of of Regional Anesthesia?

Back 61

Less alteration in cerebral function
Provides postop pain relief
Less PONV than GA

Front 62

What are 3 Disadvantages
of Regional Anesthesia?

Back 62

Time necessary to perform block
Discharge delays
Failed blocks

Front 63

Name discharge delays involving regional anesthesia that are more common in outpt than inpt.?

Back 63

hypotension
urinary retention
prolonged blockade
PDPH (post dural puncture headaches)

Front 64

Monitored Anesthesia Care involves

Back 64

IV sedation combined with local infiltration by surgeon on minor procedures

Front 65

What prevents the recall of injection of LA?

Back 65

Midazolam with propofol bolus

Front 66

Why is MAC attractive (give a pro)

Back 66

Allows for rapid discharge

Front 67

A Disadvantage to MAC is in some patients, _______.

Back 67

in some patients, light sedation can cause agitation, disorientation

Front 68

What are 2 things you can do to decrease the risk of Post op nausea and vomiting?
Some pt’s worry more than about pain

Back 68

Pretreat with 5-HT3 blocker, decadron, transdermal scope (2 hr prior)

Avoid premature po intake

Front 69

What are some associated factors that could delay discharge?

Back 69

Female
no previous GA
ETT
abdominal surgery
>20 min surgical time

Front 70

Protracted Vomiting means what?

Back 70

Hospital admission

Front 71

Uncontrolled pain means_____?

Back 71

hospital admission

Front 72

Pain post op considerations

Back 72

IV analgesics, local nerve block,
LA infiltration at surgery site

2 pain control options
IV or IM ketorolac
Oral pain med if tolerating po

Front 73

List several post op issues that can occur

Back 73

Prolonged somnolence – related to long-acting agents
Headache – common after GA
Urinary retention – esp. elderly with BPH
Sore throat, hoarse – ETT but can be seen with LMA, mask, or blocks with sedation

Front 74

Sore throat, hoarse is a post op consideration.

when is it most common?
but it can also be seen with_____?

Back 74

ETT but can be seen with LMA, mask, or blocks with sedation

Front 75

After GA headaches are_____?

Back 75

common

Front 76

Discharge Criteria

Back 76

*Alert & oriented X3
*Stable VSS for 30-60 min
*Ability to walk unassisted
*Tolerate po
*Able to void
*No significant pain, bleeding or nausea

Front 77

To be able to discharge a patient after a spinal or epidural what criteria must be met in addition to the 3 standard criteria?

Back 77

intact proprioception
minimal orthostatic changes
normal plantar flexion

Front 78

An important implication about discharge is that

Back 78

Achieving home readiness
Does not imply complete psychomotor recovery from anesthesia!
24-72 hours

Front 79

How long does complete psychomotor recovery from anesthesia take?

Back 79

24-72 hours

Front 80

What does Standard 8 for OBA practice state?

Back 80

Adhere to safety precautions, minimizinf risk of fire, explosion, shock & eq. malfunction - document anesthesia machine & eq. checked.

Front 81

What does Standard 9 for OBA practice state?

Back 81

Minimize risk of infection to pt & others.

Front 82

What does Standard 10 for OBA practice state?

Back 82

Assess anesthesia care assuring its quality & contribution to positive pt outcomes.

Front 83

What does Standard 11 for OBA practice state?

Back 83

Respect & maintain basic rights of pts.

Front 84

What depends upon the case being appropriate for the facility?

Back 84

Facility resources (23 hr admission; post op admission)
Duration of procedure (prior guideline 2hr length - not followed as strictly)
Level of post op care pts will need (preexisting condition, infection)

Front 85

What determines if the pt is appropriate for the facility?

Back 85

Medically stable ASA 3 (some 4's-limited procedure & less risk to pts health than doing in hospital)
Must be able to follow pre/postop instructions & have responsible adult at home

Front 86

What standards apply to preop evaluation?

Back 86

Same apply as inpt.
Assess appropriateness of pt/procedure for setting & determine risk.
H&P (diagnostic tests)
Informed consent
Preop instructions

Front 87

What are some intraop considerations with induction meds?

Back 87

GA being performed:
Porpofol (antiemetic, quick emergence, LMA)
Ketamine (NOT recomm b/c prolonged emergence)
Inhalation inductions acceptable (adults & peds)

Front 88

What are some intraop considerations with maintenance meds?

Back 88

Short acting opioids
TIVA acceptable
High dose narcotic (NOT recomm)
NDMR depends on length of Sx, pts health & cost
Succs drip might be good choice for short, profound relaxation (not common)

Front 89

What are some advantages of regional anesthesia?

Back 89

Less alteration in cerebral function
Provides postop pain relief
Less PONV than GA

Front 90

What aer some disadvantages of regional anesthesia?

Back 90

Time necessary to perform block
Discharge delays
Failed blocks

Front 91

What is monitored anesthesia care and an advantage & disadv?

Back 91

IV sedation combined w/ local infiltration by surgeon on minor procedures.
Midazolam w/ propofol bolus prevents recall of injection of LA

Adv: Allows for rapid discharge
Disadv: some pts, light sedation can cause agitation & disorientation

Front 92

What are some associated factors (postop) that can delay discharge?

Back 92

Female
No previous GA
ETT
Abdominal surgery >20 min

Front 93

What are some PONV considerations that may delay discharge?

Back 93

Some pts worry more about pain
Pretreat w/ 5-HT3 blocker, decadron, trans scope (2 hrs prior)
Avoid premature PO intake (ice chips)

Front 94

What are some med routes to address pain considerations postop?

Back 94

IV analgesics, local nerve block, LA infiltration at surgery site.
IV or IM ketorolac.
Oral if tolerating PO.
Uncontrolled pain = hosp admit!

Front 95

What are some other considerations postop?

Back 95

Prolonged somnolence (long-acting agents.)
Headache (common w/ GA.)
Urinary retension (eslderly w/ BPH.)
Sore throat, hoarse (ETT, LMA, mask or blocks w/ sedation)

Front 96

What are some discharge criteria pts must meet b/f achieving home readiness?

Back 96

A&O x3
Stable VS for 30-60 mins.
Ability to walk unassisted.
Tolerate PO.
Able to void.
No sign pain, bleeding or nausea.
[doesn't imply complete psychomotor recovery from anesthesia (24-72 hrs)}

Front 97

What are some important factors pts must abide by for discharge driteria?

Back 97

Never drive themselves home.
No important decisions.
Presence of responsible adult overnight in their home.