Term
| List 5 advantages of Office-Based Surgery |
|
Definition
1) Cost
2) Pt and surgeon satisfaction
3) Pt privacy
4) Same staff and efficiency
5) Decreased infection risk |
|
|
Term
| List 2 disadvantages of Office-Based Surgery |
|
Definition
1) Lack of oversight (regulation, peer review, credentialing)
2) Geographical limitations (access to hospital, ER, CC, ACLS) |
|
|
Term
| What are the 3 accrediting agencies surgical facilities? |
|
Definition
1) Joint Commission
2) American Association for Accreditation of Ambulatory Surgical Facilities
3) Accreditation Association for Ambulatory Health Care |
|
|
Term
| Where can you find office based standards for anesthesia in an office-based setting? |
|
Definition
|
|
Term
| What are some potential limitations to surgical centers? |
|
Definition
-lots of MAC sedation without anesthesia machine backup
-lack of training for ACLS and problems, people don't know ACLS except you
-No transfer protocol, how is care transferred if things go poorly? Docs usually don't have hospital privileges, so what is the plan if S hits the fan? |
|
|
Term
| In Office based surgery, death is associated most strongly with which type of anesthesia? |
|
Definition
|
|
Term
| There is a greater percentage of damaging respiratory events in office-based anesthesia or ambulatory anesthesia? |
|
Definition
|
|
Term
| List 3 advantages of MAC sedation for cosmetic surgery |
|
Definition
1) Less N/V
2) Rapid discharge
3) Good for a pt who doesn't want an ETT |
|
|
Term
| List 3 disadvantages of MAC sedation for cosmetic surgery |
|
Definition
1) lack of airway control
2) threat of aspiration
3) What to do with the anxious/uncooperative patient? you have to get them deeper and suppress respirations and lose the airway |
|
|
Term
| MAC sedation is appropriate for which cosmetic surgeries? |
|
Definition
Otoplasty (ears)
Facelift
Blepharoplasty (eyelids)
Liposuction |
|
|
Term
| What are the methods of local anesthesia used in cosmetic surgery? |
|
Definition
| Infiltration of the operative site, tumescent technique, and nerve blocks |
|
|
Term
| What is the major disadvantage of local anesthesia? |
|
Definition
| Local reactions or systemic effects (permanent or temporary parasthesia, motor weakness, necrosis, cardiac or CNS toxicity) |
|
|
Term
| The CNS toxicity treatment includes: |
|
Definition
1) Control the respiratory drive and airway
2) Stop the seizures
(and fat emulsion and the other stuff we learned from pharm and other lectures not mentioned on this slide) |
|
|
Term
| Local Anesthetic Systemic Toxicity can be worsened by: |
|
Definition
-hypoxia
-cardiovascular disease
-renal dysfunction
-hepatic dysfunction |
|
|
Term
| What pt groups respond differently to local anesthetics? |
|
Definition
-the very old
-the very young
-pregnant females |
|
|
Term
| List 4 advantages of general anesthesia for cosmetic procedures |
|
Definition
1) Amnesia, analgesia, muscle relaxation
2) Secure airway
3) Minimal risk of aspiration
4) Patient psych is missing |
|
|
Term
| List 2 disadvantages of general anesthesia for cosmetic surgery |
|
Definition
1) N/V
2) Post operative somnolence |
|
|
Term
| What ASA classes are appropriate for Office Based Cosmetic Surgery? |
|
Definition
|
|
Term
| Most breast augmentations are done under ____ ____ _____; some done with _____/___ |
|
Definition
| local with sedation, general/LMA |
|
|
Term
| list 4 benefits of an intercostal nerve block for breast augmentation |
|
Definition
1) reduced post-op pain
2) less narcotic use
3) less N/V
4) less recovery time |
|
|
Term
| List 4 problems/comlications of breast augmentation |
|
Definition
1) infection
2) hemorrhage
3) pneumothorax
4) local toxicity |
|
|
Term
| Who treats a pneumothorax during a breast augmentation in an office base setting? |
|
Definition
| You do, because you are awesome and the smartest one in the room. |
|
|
Term
| What is meant by a dry liposuction technique? |
|
Definition
| Aspiration of fat through large aspirating cannulae that is limited by subdermal bleeding. The aspirate could have up to 40% blood in it. |
|
|
Term
| How is a wetting solution technique better than a dry liposuction technique? |
|
Definition
-It contains a ratio of 1:1 normal saline to aspirate
-it distends and softens adipocytes
-small cannulas can be used
-subdermal bleeding is still present and can be hidden but aspirate contains 5-30% blood. |
|
|
Term
| What improvements were seen with adding epinephrine to the wetting solution? |
|
Definition
| larger volumes of fat could be removed, containing less than 1% blood. |
|
|
Term
| Tumescent technique solutions is composed of what 2 drugs at what concentrations? |
|
Definition
Lidocaine (0.05%-1%)
Epinephrine (1:1,000,000) |
|
|
Term
| What is the calculation for a toxic dose of lidocaine in liposuction? |
|
Definition
|
|
Term
| List 3 reasons why the toxic dose of lidocaine for liposuction so high? |
|
Definition
1) Epinephrine is being added
2) Injected into SQ tissue (low re-absorption rate)
3) Fat hangs on to lidocaine |
|
|
Term
| List 3 things that the tumescent technique provides/allows for |
|
Definition
1) liposuction strictly under local anesthesia
2) Minimal blood loss
3) Post operative analgesia |
|
|
Term
| What is the maximum dose of epinephrine for tumescent anesthesia? |
|
Definition
|
|
Term
| In liposuction, what drugs are metabolized by the Cytochrome P450 pathway that is used by lidocaine, resulting in a longer duration of action for these drugs? |
|
Definition
Tagamet
Beta Blockers
Anxiolytics |
|
|
Term
| What drug can interfere with lidocaine levels to raise the seizure threshold (masking seizures in lidocaine toxicity) |
|
Definition
|
|
Term
| What are common diseases associated with people getting liposuction? |
|
Definition
|
|
Term
| one technique to mix tumescent solution is in a 1 liter bag of saline: add __ -___ml of __% lidocaine and __ ml of _:____ epinephrine |
|
Definition
| 50-100ml, 1%, 1ml, 1:1000 |
|
|
Term
| List 5 considerations for periop management for liposuction |
|
Definition
1) large bore IV with warm fluids
2) Prepped standing
3) room temp up
4) Pt lies on sterile drape on the table
5) positioning can be challenging |
|
|
Term
| What is the intraop fluid management for a small volume lipoplasty (<4L aspirate) |
|
Definition
| maintenance IVF + SQ wetting solution |
|
|
Term
| What is the intraop fluid management for a large volume lipoplasty (>4L aspirate) |
|
Definition
| maintenance IVF + SQ wetting solution + 0.25ml of crystalloid per ml of aspirate >4L |
|
|
Term
| Maintenance IVF calculation for liposuction |
|
Definition
|
|
Term
| It is estimated that ___% of the wetting solution will be removed from the lip aspirate. So for every _____ of solution infused, ____ml remain in the body absorbed. For this reason maintenance fluid may be the only volume required. |
|
Definition
|
|
Term
| What is the fate of the tumescent fluid? |
|
Definition
-enters lymphatic system or vascular system
-60-70% will reabsorb
-tricky fluid management because they can develop hypovolemic shock or fluid overload |
|
|
Term
| __-__% of the tumescent fluid will reabsorb |
|
Definition
|
|
Term
| What postop complication is most likely to cause death following plastic surgery? |
|
Definition
|
|
Term
| List the 4 etiologies of death in plastic surgery |
|
Definition
1) pulmonary thromboembolism (23%)
2) perforated viscouse (4%)
3) fat embolism (8%)
4) cardiorespiratory failure (4%) |
|
|
Term
| When does death usually occur after plastic surgery? |
|
Definition
|
|
Term
| Anesthesia factors contribute to ___% of deaths related to plastic surgery |
|
Definition
|
|
Term
| List 5 factors that increase fatality in plastic surgery |
|
Definition
1) IV sedation vs general technique
2) multiple concurrent surgeries
3) fat aspirate > 5,000 ml
4) large doses of lido used
5) excessive administration of IV Fluid |
|
|
Term
| Liposuction produces a ___ ___ injury under the skin |
|
Definition
|
|
Term
| Blood tinged aspirate with tumescent liposuction has an HCT of __%, less than ___ml of blood per liter of fat |
|
Definition
|
|
Term
| What is normal lido toxicity |
|
Definition
4ml/kg with epi
7ml/kg without epi |
|
|
Term
| Lidocaine binds to subdermal tissue (__gram of tissue binds to __mg of lidocaine) |
|
Definition
|
|
Term
| signs of lidocaine toxicity |
|
Definition
circumoral and tongue numbness
lightheadedness
tinnitus
visual disturbances
muscle twitching
convulsions
unconsciousness
TOXIC: coma, respiratory arrest, CVS depression |
|
|
Term
| Treatment for lidocaine toxicity |
|
Definition
Stop injection and give O2 and manage airway
Lipid therapy
treat seizure
succs to intubate |
|
|
Term
| how would you treat the seizure in LAST? |
|
Definition
|
|
Term
| Lipid emulsion dosing in LAST |
|
Definition
1.5ml/kg bolus of 20% Lipid emulsion
then 0.25ml/kg/min |
|
|
Term
|
Definition
Tissue blood flow rankings from highest to lowest
1) Trachea
2) intercostal muscles
3) caudal
4) paracervical
5) epidural
6) Brachial plexus
7) subarachnoid, sciatic, femoral
8) subcutaneous (slowest absorption) |
|
|
Term
| Analgesia with tumescent has an ___ hour duration (up to ___hours) |
|
Definition
|
|
Term
| What is the #1 mortality culprit for liposuction? |
|
Definition
|
|
Term
| List 4 postop considerations for liposuction |
|
Definition
1) analgesia from tumescent lasts for 18 hours (up to 24 hours)
2) Surgical binders impair ventilation
3) PE is #1 cause of mortality
4) some stay over night stay with pulse ox |
|
|
Term
| factors that increase risk of venous thromboembolism (from article) |
|
Definition
-VTE history
-hormone replacement therapy
-obesity
-oral contraceptives
-advanced age
-recent travel
-pregnancy
-immobility
-smoking
-cancer
-hypercoagulable blood disorders
-recent MI
-CHF
-general anesthesia
-long procedures
-combined procedures (especially with abdominoplasty) |
|
|
Term
| Which procedure has the greatest risk of VTE |
|
Definition
| Abdominoplasty especially if combined with other procedures |
|
|
Term
| What is a big issue with abdomnioplasty? |
|
Definition
|
|
Term
| List 5 considerations with facial cosmetics |
|
Definition
1) usually local with MAC
2) Nasal packs (including cocaine)
3) antihypertensives (clonidine 0.2 mg po) to lower perioperative BP, swelling, and blood loss
4) dexamethasone (swelling)
5) OR fire may be a concern |
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