Anesthesia for Ambulatory Surgery

Financial - reduced medical cost, reduced outside costs like childcare, resumption of normal (work) activities. Cost containment for 3rd party payors.

Medical - increased availability of inpt hospital beds, decreased risk of nosocomial infections.

Social - children have minimal separation from parents, minimal separation from family and routine for elderly minimizes cognitive and physical aberration, less medication means less confusion in outpt geriatric patients. Basically, anyone returning to a familiar environment and routine earlier does better.

Staff - better use of time, uniform scheduling, more predictable surg outcomes.

1) extensive blood loss
2)big physiological shifts of considerable fluid volumes
3) procedures involving prolonged immobilizations.
4) Active Substance Abuse (impaired autonomic and cardiovascular responses)....pt must detox first.
5) Premature Infants (< 37 weeks gestational age) due to risk of aspiration and apnea. (These are not eligible for otpt sx until > 60 wks postgestational age.)
6) Full Term Infants less than 2-4 weeks old.
7) Infants with a hx of SIDS or at risk for SIDS, current respiratory difficulties, apneic episodes, failure to thrive, feeding difficulties, or ANEMIA (Hct < 30%).
8) Patient's exceeding 85 years of age
9) Pt's with UNCONTROLLED seizure disorders.
10) Pts with cystic fibrosis AND respiratory distress.
11) Pts with Malignant Hyperthermia Susceptibility AND who demonstrates increased temp, myoglobinuria, or elevated CK levels or an MH episode.
12) BMI >35 or 40. And morbidly obese pts with other comorbidities.
13) Pt's with Reactive Airway Disease that is symptomatic.
14) Uncontrolled or Active Sickle Cell Disease.
15) ASA class III or higher.
16) Previously unevaluated and unmanaged OSA
17) Current sepsis or infection requiring isolation
18) Expected post op pain that cannot be controlled with home meds or local LA techniques.
19) Expected lack of compliance or home care.

1) Procedure - should have insignificant incidence of intra- & post-op problems; doesn't require intense postop pt care.

2) Health of Patient - pt ideally in usual good health; if ill, issue is well controlled; pt/family receptive to outpt philosophy

3) Surgeon skill and cooperation

Helps you determine how much anesthesia will be needed...chronic abusers may have increased CYP450's and increased metabolism/ tolerance of anesthesia.

Also, Acute/ Active substance abuse is a contrainidication for outpatient sx.

Infiltration of wound with LA; LA catheter in wound for cont/intermittent dosing.

Prophylactic use of NSAIDS.

Risk of physiological aberrations.

1) exhibit anemia
2) Increased aspiration risk d/t undeveloped gag reflexes
3) Increased risk of hypothermia d/t immature temp autoregulation. This can cause postop apnea.
4) Immature brainstem fx --> can predispose preemie to pathologic respiratory conditions.

Can drop to 7-8g/100ml

Anemia in newborn is defined as Hematocrit < 30% and predisposes infant to apnea.

Delay sx until the Hct is > 30%.

Short apnea lasts 6-15s.

Prolonged apnea lasts >15s.

Periodic breathing is 3 or more periods of 3-15s apnea seperated by less than 20 seconds of normal breathing.

Short apnea, prolonged apnea, or periodic breathing all predispose the infant to hypoxia & bradycardia.

The premature infant can develop prolonged apnea as late as 12 hours after surgery.

The older the infant, the less likely these problems will occur.

An infant with a hx of apnea or bradycardia must be apnea free and without monitoring for at least 6 months to be considered for outpatient sx.

When their post-gestational age is greater than 50-60 weeks.

If you use an ett on an infant/preemie, you should assist or control ventilations B/C of the resistance and increased WOB caused by ett and circuit.

At the Y.

If either of the unidirectional valves fail, then that part of the circuit becomes part of the deadspace.

Decrease length of circuit & ett.

Patients at risk for developing SIDS should not be considered for outpatient sx until they are 6 months to 1 year old.

Hx of apnea - an infant with a hx of apnea & bradycardia must be apnea free and not monitored for at least 6 months to be considered for outpt sugery.

Infants with s/sx of bronchopulmonary dysplasia are not considered for outpt surg d/t increased risk of SIDS.

Those are increased risk of SIDS are not candidates for outpt surg until they are min 6 mos - 1 year old.

Full term infants with hx of apnea, failure to thrive, feeding difficulties.

Infants with hx of resp difficulties at birth unless they are free of resp sx at time of surg and time of d/c.

Congenital Diaphragmatic Hernia - d/t hypoplastic lung on affected side.

Uncontrolled asthma - can try nebulizing or puffing them before you delay/cancel.

Those with bronchopulmonary dysplasia.

Infants with a hx of apnea.

Have sibs who died of SIDS.

1 month - 1 year of age.

85 years old...but this is NOT an exclusion criteria.

Absence of adequate support at home post-op.

Uncontrolled diabetes mellitus

Poor control of a persistent (ASA III or IV) disorder and/or evidence of end organ involvement.

Uncontrolled seizure activity

CF patient wiht sx-atic respiratory distress.

Morbidly obese pt with significant presxisting cardia, hepatic, pulmonary or renal disease.

Reactive Airway Disease pt when indications for a chest radiograph or ABG are met.

Active sickle cell crisis.

Active etoh/substance abuse

Previously unevaluated/unmanaged OSA

Uncontrolled diabetes

Active sepsis or infection requiring isolation.

Anticipated postop pain not expected to be controlled iwth LA or oral analgesics

Sickle cell patient - need extended postop obs. and need to hydrate pre-op.

Seizure d/o - need 4-8 hours postop obs.

Malignant Hyperthermia - need to monitor at least 2.5 hours if no jaw tension observed; need to monitor 12 hours if jaw tension observed.

Morbidly Obese - prolonged observation

OSA - prolonged postop obs. Lots of stuff to go wrong here.

DM - to get them back on their PO intake asap.

Those requiring long-acting spinals - to give time to recover from SNS blockade effects.

Previous episode of MH

Masseter muscle rigidity with previous anesthesia.

First degree relative with hx of an MH episode or positive muscle biopsy.

Minium of 36 vials of dantrolene.

temp rise, myoglobinuria, elevated CK levels, progression to MH episode.

TRUE

If BMI> 35-40 or they have comorbidities then they should not have sx as an outpatient.

CPAP should be available for use in the immediate post-op recovery phase.

No - use nonopiod analgesics, LA wound infiltration,

Only if the patient has a suspected acute infiltrative process or if they have deteriorated physically.

And if this occurs they are NOT a candidate for outpatient sx.

Intraoperatively, the sickle cell patient is at risk for crisis if they experience acidosis, dehydration or hypoxia.

No major organ disease s/t sickle cell.

No sickle cell crisis for 1 year.

Compliant with prescribed medical care.

On D/C, should be within 15 minutes travel time to facility prepared to care for patient

Receive close follow-up care.

Not a prolonged procedure nor associated with blood loss.

Able to arrive early so adequate IV hydration can be implemented.

Postop problems may require intubations; since sux is not an option, you have to give a whomping dose of a ndNMB agent to secure the airway. Then, do you have the ability to adequately ventilate the patient?

Transfer agreement with inpt facility for seamless admission.

Emergency difficult airway equipment.

Concensus on availability of airway equipment.

Radiology facilities for portable chest radiograph.

Clinical lab facilities (abg, lytes)

Sleep apnea status

Anatomic and physiologic abnormalities.

Status of co-existing disease(s).

Anticipated need for postop opioids.

Patient age (which, apparently, is a factor when you have OSA).

Airway surgery (adult)

Tonsillectomy in children <3 years old.

Laparoscopic or abdominal surgeries.

Formalized preanesthetic clinic

Sufficiently in advance of scheduled surgery to allow time for testing or procedures.

The high risk patient shold be evaluated at least 1 week before the scheduled procedure.

Otherwise healthy patients who do not have the chance to visit the clinic preoperatively can be evaluated on day of surgery (higher risk of postponement or cancellation with last-minute discovery).

FALSE - Routine lab screening is neither cost-effective nor predictive of postop complications.

No - a seperate anesthesia history should be incorporated into a questionnaire specifically designed for preanesthetic eval.

Patient eval should be conducted w/in 30 days of surgery for medically stable patients.

This should occur within 72 hours of surgery for high risk patients.

6 months

Exceptions are:
Serum K+ - within 7 days of surg for patients on diuretics or digoxin.

Blood glucose levels - Need to be tested on the day of surgery for diabetics.

It can worsen the OSA.

Patient's seizure should be managed and they should be admitted for overnight observation.

If H&P indicate patient may be pregnant or if pregnancy may complicate surgery.

Female staff should question adolescent females in absence of family members.

TRUE

Those who have/have had:

Hepatic disease
Exposure to hepatitis
Therapy with hepatotoxic agents

No

Those who are on digoxin or diuretic therapy.

Patients with:

Hematologic Disorder
Vascular procedure
on Chemotherapy
Unknown sickle cell syndrome status.

Age <6 mos.if term; <1 yr if preemie.
Hematologic malignancy.
Recent radiation or chemo.
Renal disease.
Anticoagulant therapy.
Procedure with high to moderate blood loss potential.
Coexisting systemic d/o's that would predispose to aberration in H-H levels.

DM
current corticosteroid use
Hx of hypoglycemia
Adrenal disease
Cystic fibrosis

Leukemia
Hepatic disease
Bleeding d/o
Anticoagulant thx.
Severe malnutrition or malabsorption.

Bleedign disorder
Abnormal hemorrhage, purpura, easy bruising.

Just look at BOX 38-4 on p. 899 in Nagelhout

Patients at risk for CV disease (cocaine abuse, HTN, renal disease, circulatory disease, thyroid disease, DM & > 40 y.o., significant pulm disease)

Hx of previously unevaluated pathologic sounding murmur or palpitation.

Family hx reveals possibility of inherited prolonged QT syndrome.

Hx of moderate to severe sleep apnea or chronic anatomic airway obstruction b/c this may present risk fo R-sided heart strain.

FALSE - data suggests that clears up to 2-3 hours preop did not increase gastric vol nor decrease gastric pH at time of elective surgery.

Hypothyroidism
DM
Hepatic failure
Hyperglycemia
Obesity
Renal failure
Uremia (clinical syndrome associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function)
Pregnancy

Age Extremes
Anxiety
Ascites
Scleroderma
Depresion
Esophageal Sx
Opiod, barbituate and anticholinergic administration
Difficult airway
GI obstruction or hiatal hernia
Hypothyroidism
DM
Hepatic failure
Hyperglycemia
Obesity
Renal failure
uremia
Neurologic sequelae
Pain
Pregnancy
Prematurity
Smoking
Type and composition of gastric contents.

Cardiopulmonary meds should be continued on the morning of surgery.
Adults should take them with 150 mL of water and children should take them with 75 mL of water up to ONE hour before sx.

Clear Liquids - 2 hours.
Human Breast Milk - 4 hours
Non-human milk/infant fomula - 6 hours
Light meal (toast and clears) - 6 hours.

Coumadin should be d/c'ed 4-5 days before surgery. A PT/INR should be drawn on day of surgery. Consider LMWH sq as a bridge and a medical consult.

Refer that outpatient candidate for inpatient surgery.

They should be scheduled as early in day as possible.

NPO after MN if early surg time.

Serum glucose on arrival via fingerstick or lab draw.

Prevent hypoglycemia while maintaining blood glucose levels < 180 mg/dL.

Return to preop ADLs asap (baseline activity and nutrition habits).

Make patient aware that admission to hospital is likely for persistent N/V, with will prevent resumption of normal dietary intake.

An innocent murmur is totally asymptomatic.

A pathologic murmur may be d/t congenital malformations, heart disease and cause physical dysfx.

"Whether the murmur is benign, functional or caused by organic heart disease, cardiologic assessment should be obtained before induction of anesthesia." -Nagelhout p.901

If it is recently acquired (in past 12-24 hours) or is chronic rhinorrhea in an otherwise fit child.

You have to do a nasal culture to see of it is caused by an infection. If it is infectious...delay sx for 2-4 weeks.

Only 2 weeks.

Get a nasal and throat culture.

NON-infectious: due to allergic rhinitis or vasomotor (crying, temperature)

INFECTIOUS - d/t viral infections (common cold, chickenpox, measles) or bacterial infections (streptococcal tonsillities or meningitis)

URTI

Elevated WBC (> 12,000 with a left shift).
Mucopurulent nasal secretions
Inflamed and reddened mucosa. (NOTE: if pt has allergic rhinitis, the nasal mucosa is ashen and boggy)
Positive chest findings (rales, etc.)

Temp 37.5-38 C (T>38 usually r/t LRTI).
Tonsillitis
Viral ulcers in orpharynx.

Yes - two to seven fold.

They are more likely to have laryngospasm, hypoxemia, increased secretions, bronchospasm, PNA, atelectaiis, croup, stridor, etc.

No - esp if chest sounds are clear.

ett intubation (<5 y.o.)
Hx of prematurity
Hx of Reactive Airway Disease
Paternal smoking
Surgery involving airway
Presence of copious secretions
Nasal congestion

breath-holding, bronchospasm, coughing, hypoxemia, increased secretions, laryngospasm, pneumonia, atelectasis, croup and stridor.

TRUE - A child with an URTI can still have elective sx as long as the following conditions are met:

1) They are asymptomatic (nonpurulent nasal secretions, normal chest xray), and healthy with no other illnesses.
2) Age > 1 year
3) Surgery is NOT of the thorax or abdomen
4) ETT is not used. (LMA is preferred with URTI).

Cancel surgery and reschedule for at least 4 weeks out.

Older than 1 year of age.
Surgery not on thorax or abdomen
No other illness that may complicate periop pt mgmt.
Ett intubation not planned. (LMA is preferred b/c ETT can increase risk of resp complications by 11 fold.)

Potential to delay discharge/prolong pt. stay.

Yes - preoperatively. They have been shown to reduce postop pain by preventing surgical induction of peripheral and central sensitization.

ANTACIDS - increase pH/decrease acidity rapidly (15-20 min). Disadvantage is they increase gastric volume. Use nonparticulate's b/c will not cause pulmonary injury if aspirated. (Alka Seltzer Gold or 30 mL of Sodium Citrate).

GASTROKINETICS - reduce gastric volume w/o decreasing gastric pH. Reglan 10 mg. Must take preop 30-120 min before sx if taken po. 30 min preop if taken IV. Reglan Increases lower esophageal sphincter tone, increases GI motility, and blocks dopaminergic CNS receptors to prevent nausea.

H2 RECEPTOR AGONISTS - block H+ -ion release by gastric parietal cells. Cimitedine, famotidine, ranitidine. This DO NOT alter the pH of gastric fluid already present in stomach.

PROTON PUMP INHIBITORS - intracellular inhibition of gastric acid secretion in humans w/o affecting gastric volume. Inhibit the proton pump directly. Omeprazole (Prilosec) 40 mg IV given AFTER INDUCTION. or 80 mg PO given the night before sx. Pantoprazole (protonix) given IV 40 mg.

Avoid particulates (maalox, mylanta)

ALWAYS USE: Clear, nonparticulate b/c these are less damaging to the lungs in case of aspiration.

2 tabs alka-gold in 30 ml H20
30 ml of sodium citrate/bicitra

Metaclopromide/Reglan 10-20mg IV over 3-5' at least 30-45 min before surgery. Peaks 40-120 min after admin.

Children: 0.1 mg/kg

Works with H2 antagonist to drop gastric volume & raise gastric pH. Reglan also increases lower esophageal sphincter tone and blocks dopaminergic receptors in the CNS to prevent nausea.

TRUE - (Reglan does it all!)

Can admin night before surg, a.m. of surg or both. These meds primarily decrease the risk of chemical pneumonitis should aspiration occur.

Cimetidine: PO - 300 mg for adults & 7.5 mg/kg children 1.5-3 hours before surgery.

Famotidine: IV: 20 mg 15-30 min before surgery for adults. PO: 40 mg PO night before and a.m. of surgery.

Ranitidine: IV: 50-100 mg or 1.0-2.5 mg/kg for adults. PO: 150-300 mg for adults; 2.5 mg/kg for children, given 1-3 hours before surgery.

Omeprazole/Prilosec: IV: 40 mg for adults given after induction of anesthesia. No sig SE. PO: 80 mg given evening before surgery.

Lansoprazole/Prevacid 30 mg & Rabeprazole/Aciphex 20 mg PO given day prior to surgery and on morning of surgery. Not as effective as ranitidine.

Pantaprazole/Protonix: IV 40 mg adults.

one with rapid onset and offset, short beta-elimination half-lives, inert metabolites and insignificant side effects.

GA should be done with less blood-soluble inhalation agents or with short acting IV agents with capability of reversal.

Use rapid on/off inhalational agents (Des/Sevo) + IV agents (propofol, IV opiods, short acting NMBs, NSAIDS).

BIS monitoring correlates well with levels of sedation & amnesia.

Outpatient Advantages:
Reduces the amt of anesthetic agent required.
Faster emergence from anesthesia.
Reduction in Phase II vomiting.

Prolonged resumption of dietary intake.
More meds given to ett pt vs. mask pt.
Irritation and trauma to upper airway (especially in children, whose cricoid cartiledge is the smallest diameter).
Delayed patient discharge (d/t all the meds given and delayed po intake).

Minimize intubation trauma.
Ensure air leak present at <40 cmH2O.
Avoid lg diameter ett.

Less coughing, smaller analgesia requirements, and less sore throat following ambulatory surgery.

1) Procedures >30 min (Long procedures increase hypothermia risk, amt of anesthetic used, and delay resumption of normal diet.)

2) Procedures with increased risk of PONV (permits admin of hydration and antiemitics IV.)

3) Procedures assoc with postop discomfort (for IV analgesia if noninvasive approach is ineffective).

4) Prolonged fasting (>15 hours of fasting make IV fluids necessary for hydration and glucose homeostasis)

5) Procedures assoc w/intrap & postop bleeding.

6) Procedures or patients requiring perioperative antibx tx.

Local wound infiltration, PNB, IV regional (bier block), opthalmic blocks (retrobulbar or periorbital); brachial plexus anesthesia, spinal anestehsia and epidural anesthesia.

The shortest acting agent capable of providing satisfactory blockade...to avoid delays in recovery.

Can provide pain relief up to 24 hours.

Shorter recovery times vs GA
Decreased incidence of inpt admission.
Phase-I bypass eligibility high
Better Postop pain relief.
Better postop pain scores vs GA.
Common Side Effects assoc w/GA are minimized.
Satisfactory alternative for patients who fear "loss of control" with complete sedation.

Requires cooperation of patient & surgeon w/ anesthesia.

Regional may require more time vs GA. May not have adequate staffing to perform blocks/regional and keep pace of surgery center. Therefore it might not be well received by the surgical team.

Inherent Regional anesthesia problems (sympathetic blockade assoc with spinal and epidural --> HOTN can delay discharge)

AXILLARY BLOCK - preferred method for forearm & hand; least likely to cause complications. (misses the musculocutaneous nerve.)

INTERSCALENE BLOCK - most popular for shoulder surgery. Less risk of side effects, lowest risk of pneumothorax..BUT...has a risk of intradural injection of LA, vertebral artery puncture, and stellate ganglion, phrenic nerve, or recurrent laryngeal nerve block.

SUPRACLAVICULAR BLOCK - ideal for arm surgeries; small risk of pneumothorax. The "money block" - blocks everything.

INFRACLAVICULAR BLOCK

All good for arm or shoulder surg.

DETAILED written instructions to patient and caregiver AND arm supported in a sling.

Risk of :

Intradural injection of LA
Vertebral artery puncture
Stellate ganglion, phrenic nerve or recurrent laryngeal nerve block.

Absence of HOTN after block given (as compared to spinal) and
Superior recovery features.

Caudal anesthesia is normally only used for perineal and pelvic surgeries or for analgesia in pediatrics.

Offers no advantage.

Reduced incidence of PONV
Lower incidence (vs spinal) of post dural puncture headache.
Control over block is greater.
Changes in BP are fewer.
Can titrate to effect when using a short to intermediate acting LA (chloroprocaine, lidocaine, mepivacaine) thru a continuous catheter.

Slower onset (vs GA or spinal)
Less reliable block than spinal.

simple to perform
Rapid onset with reliable results.
Rapid offset once tourniquet is deflated.
Costs less (half the cost)
Fewer postop complications vs GA
Shorter D/C times vs GA.
Does not have to be limited to adults (can use with kids undergoing outpt arm surgery).

1) Ankle Blocks (five nerves blocked). Must place before going to OR. Can provide anesthesia and 12-24 hours post op analgesia.

2) Popliteal fossa and sciatic nerve blocks

an entire leg.

yes...if patient is given proper instruction and preparation, risk of injury with an insensate limb is minimal.

Fewer delays in onset of the block....pt spends less time in the preop holding room.

Prolonged SNS blockade and HOTN/urinary retention risk in GERIATRIC POPULATION.

PDPH
Orthostatic HOTN
Urinary retention
Transient Neurological Sequelae following concentrated hyperbaric LAs.

Lidocaine and procaine.

Lidocaine alone is allowed for surgeries <1 hour.

Add epi 0.2-0.3 mg or phenylephrine 1-5mg to lidocaine for surgeries of 1-2 hours.

If the LA wears off and the sx is still going on, surgeon can infiltrate a longer lasting LA into the site to prolong the block until he is done.

Tetracaine & bupivicaine.

Adding vasoconstrictors to these is not advocated. (Tetracaine and bupivacaine are avoided because of their prolonged durations. They can only be used if the sx is going to last more than 2 hours and sx is early in the day).

TRUE

Danger of orthostatic HOTN when attempts to ambulate are made in Ph II recovery.

Can be caused by residual spinal anesthesia.

Post-Dural Puncture Headache

No, b/c of risk of incapacitating PDPH.

72 hours - in case tx of PDPH is necessary.

Symptoms can occur for days after the spinal:

MILD HEADACHE: bedrest, analgesics, oral hydration, oral caffeine. (Pt can lie flat...this has no effect on anything.)

SEVERE HEADACHE - epidural blood patch done outpt.

No

A set of temporary pain or dyesthesia sx involving the back and legs afer complete resolution of a spinal anesthetic, appearing between 1- 24 HOUR AFTER THE RESOLUTION OF A SPINAL BLOCK. It is caused by a lidocaine-induced increase in intracellular Ca2+.

Usually resolves in 1 week.

Risk Factors: Spinal Anesthesia with Lidocaine. Knee arthroscopy using a tourniquet & gyne/uro- procedures done in lithotomy position. Outpatient status increases risk d/t early ambulation, especially in the obese.

Tx: NSAIDS & more potent analgesics pt was prescribe postop. Time.

Transient urinary retention s/t sympathetic & parasympathetic block at s2-s4 level of nerves ennervating bladder, detrusor & sphincter muscles causing loss of bladder tone and loss of reflex to void.

Can require catheterization and prolong discharge or lead to inpt admission.

More common in males.

Influenced by duration of block.

Reduce total amt of LA used for spinal.

Use shorter acting LA (lidocaine, chlorprocaine)

Add fentanyl to LA ("Reducing the amt of lidocaine from 50 to 20 mg by adding 10-25 mcg of fentanyl has a beneficial effect of reducing the time to pt voiding by approximately 30 minutes").

Omit adding epi to lidocaine b/c it prolongs block duration and micturation.

Careful attention to IVF so you avoid bladder overdistention.

IF these steps are used and IF the procedure is not assoc with urinary retention, pt can go home w/o voiding.

B/C of its superior recovery profile.

Increased patient comfort - use short acting opioids titrated until therapeutic effect.

PONV and pain.

A minimum score of __12__ out of __14___ is required on the White's Fast Tracking Scoring system to bypass Phase 1 recovery and go straight to a short-stay unit (Phase 2).

48

PONV and Pain are the most common postop complications requiring inpt admission following ambulatory surgery.

Laproscopic sterilization
lap inguinal herniorraphy,
head & neck procedures
Ear, nose & throat procedures
Urologic procedures
orthopedic procedures

Age: kids between 3-12; gradual decrease in PONV after 50 y.o.

Apprehension: anxiety may increase risk of vomiting.

Gastroparesis: delayed gastric emptying means greater gastric content and greater chance of vomiting.

Gender: adult females more likely; no difference in gender after 70 y.o.

Individual predisposition: prior hx of PONV or motion sickness

Recent food ingestion

Nonsmoker status: smokers are at LESS risk of PONV

Type of surgery: prolonged surgical times increase risk of PONV

Premedication with Opiods: longer lasting opioids impair GI motility and cause serotonin release from the small intestines...this activates the vagus nerve.

Induction: Gastic distention with inhalational induction from positive pressure ventilation via face mask (can also occur with IV induction is pt is mask ventilated); propofol produces less PONV than etomidate/thiopental/ketamine/methohexital

Maintenance: PONV increased with longer anesthesia times, GA more than RA/LA, Isoflurane (older) vs newer (Des, Sevo) agents, volatiles > IV hypnotics, intraop opioids increase PONV, N2O increases PONV due to middle ear pressure, gut distention, and interaction with opiod receptors.

Ambulation: common in ph2 recovery ( due to postural HOTN)

Postural HOTN: dizziness, syncope & nausea when BP drops on standing. (Dehydration causes pulling on the meninges which causes nausea.)

Uncontrolled pain: increased catecholamines and serotonin release

Postop admin of opioids.

Oral intake before d/c from Phase II recovery: intake of oral fluids can increase risk of PONV.

Lower FiO2%: supplemental O2 may offer short-term benefit in decreased PONV. This is because it prevents intestinal ischemia...so if your pt has has intestinal sx or laproscopic sx, make sure they get post op O2.

Reversal agents: Opioid and benzo receptor antagonists & neostigmine > 2.5 mg may increase PONV.

Withold PO & maintain IVF with LR or NS.

Multi-modal prophylactic antiemitic therapy.

Acupressure/-puncture: P6 point stimulation. - causes endorphin release.

Emind/Aprepitant: Neurokinin-1 receptor antagonist; 40 mg PO w/in 3 hours of induction.

Dexamethasone (Decadron): 5-10 mg IV for adults, solo or in combo; 0.0625 mg/kg for children; give immediately after induction to avoid perineal pruritis. Extends to Phase III (at home). Only give with surgeon's permission because it can delay wound healing. Avoid with DM.

Dolasteron/Anzemet: selective serotonin type 3 antagonist; 12.5 mg IV given 15 min before end of anesthesia or 100mg PO 1-2 hours preop.

Droperidol: (a dopamine receptor antagonist): a low dose: 10-20 mcg/kg IV; FDA black-box warning - use 12 lead EKG 2-3 hours post administration...can prolong the QT interval.

Ephedrine: indirect acting sympathomimetic agent; 10-25 mg IV to prevent PONV associated with postural HOTN of ambulation.

Gastric Suctioning: may actually INCREASE PONV.

Metaclopromide/Reglan: increases LES tone; promotes gastric emptying by increasing small bowel motility via antiserotonin & antidopaminergic effects. Ineffective at low doses (10 mg); is effective at higher doses (0.15 mg/kg) as antiemitic when used with Decadron.

Midazolam/benzos: 50-75 mcg/kg IV children & 2 mg IV adults as premed/intraop/rescue. Good for strabismus surgery PONV.

Ondansetron; selective serotonin type 3 receptor antagonis; 0.15 mg/kg IV over 2-5 minutes at end of surgical procedure.

Promethiazine/Phenergan: 5-10 mg IV for prophylaxis and rescue.

Scopolamine: transdermal; 2-4 hours preop or overnight if possible.

Stress response (elevated catecholamine levels, increased O2 consumption, increased cardiac work, tachycardia); pt uneasiness, neurohumoral response (increased stress hormones and aldosterone); increased N/V; psychological distress, discharge delays and unanticipated hospital admission.

Preop and Intraop....don't wait til postop.

TRUE

Non-opioid analgesics....they improve overall analgesia, promote early ambulation, and minimize opiod related side effects.

8

VSS and w/n 20% of baseline
Alert and oriented x 3
Home caregiver avaliable if needed.
No respiratory Distress
swallow & cough protective reflexes present.
Bleeding is appropriate to surgical procedure and minimal.
Pain minimal or controlled with an appropriate level of analgesia
Nausea and vomiting minimal.
Oral intake prior to discharge is not necessary unless crucial to the pt's condition (ex: diabetic, oral analgesics, etc).
Voiding is not mandatory before discharge except for patients at high risk for postop urinary retention (hx of post op urinary retention, pelvic or urologic surgery, perioperative catheterization).
Status of these parameters not likely to deteriorate.

TRUE

48 hours.

See Box 38-13 on p 913 Nagelhout.

1) Smaller degree or pt privacy
2) Pt must make preop and post op trips to MD.
3) Adequate home care must be avaliable
4) There can be problems with patient compliance and efficacy.
5) Children have less time to adapt to the surgical setting.
6) Decreased Observation Time and Monitoring.

False

Length of surgery is not a good indicator of success of outpatient surgery. Better to go by the procedure and type of anesthetic technique.

BEFORE going to the OR.

Brachial Plexus blocks take 15 minutes or longer to reach therapeutic effects.

Ankle blocks take time to block the 5 ankle nerves and also there is a delayed onset of action.

Therefore the block should be placed BEFORE going to the OR.