Discharge after ambulatory surgery

1
Discharge after ambulatory surgery

• Current Anaesthesia Critical Care
• 2004 15, 331-335
• Resident ???

2

• Appropriate discharge of patients after Day
  Surgery is a multifactorial problem
• Ries (1899) patient improved with earlier
  ambulation and suffered fewer complications
• Cushing (1900) performed inguinal hernia repair
  under cocaine local anesthesia
• A safe practice with complication-related
  admissions at 0.15

3

• 1994 over 60 of all surgical cases in USA being
  ambulatory
• Selection criteria evolved to deal with both the
  expanding range of surgery and the broader
  categories of health status of patients
• Save costs, fewer nursing staff, fewer beds and
  popularity with patients

4

• Time to discharge from an ambulatory unit is a
  measure of the efficiency of the unit and is
  important to non-practitioners
• At discharge, patient should be home-ready
  (alert, stable vital signs, absence of bleeding,
  adequate analgesia, no N/V)

5
The recovery period

• Discharge patient must be fully recovered from
  anesthesia and back to their pre-op physiologic
  state
• Gradual, largely complete in Hospital, the final
  phase is completed at home

6

• Three phase
• I Termination of surgery/anesthesia to the
  return of protective reflexes and motor function
  (min)
• II End of phase I to discharge (hr)
• III Discharge to full recovery (days)

7
Aldrete Scoring System (1970)
10 Maximum score 9 Attained Phase II
of recovery
8
Modified version of Aldrete score

• Adds 5 other variables
• Pain, ambulation, dressing, ability to eat,
  ability to void
• Oxygen saturation gt92 on room air
• 18 out of maximum score 20 plus adequate
  saturation indicates home readiness

9
Post anesthetic discharge scoring system (PADSS)
BP,HR, temperature
Score gt 9 indicates fitness for discharge,
escorted by a responsible adult
10
Psychomotor impairment tests prior to discharge

• SRT simple reaction time
• CRT choice reaction time
• CFFT critical flicker fusion time
• DSST digit symbol substitution test
• PAT perceptive accuracy test
• Digit span
• California verbal test

11

• Disadvantage require equipment and personnel
  trained to use, time consuming, assess only one
  area of brain function, patient may complete the
  tests successfully, but still nauseate and in pain

12

• Patients are given written instructions about
  activity in first 24 hr after discharge
• Advice not to drive, drink alcohol, operate
  machinery, cook, care for children and sign
  important documents
• Other parameters temperature, after SA,
  orthostatic BP

13
Regional anesthesia delays discharge myth or
reality ?
14
Advantage

• Optimal pain relief
• Quicker discharge
• Lack of cognitive dysfunction after GA

15
Problems

• Lack of sensation over the dermatome served by
  the nerve
• Post dural puncture headache following SA limited
  the popularity of this modality of regional
  technique in ambulatory anesthesia (lt1)
• Suitable criteria include normal S3,4, 5
  peri-anal sensation, foot plantar flexion and
  hallux proprioception

16

• Voiding before discharge after neuroaxial
  regional techniques is usually required in
  concern of bladder distension and dysfunction
• Study 201 patients at low risk of urinary
  retention, standard or accelerated group, receive
  SA/EA.
• Mean discharge times for accelerated group were
  22 min less than the standard group

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Is it compulsory for patients to void prior to
discharge ?
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• Controversial
• Mandatory voiding can lead to delays in discharge
• Risk factors for discharge include a previous
  history of retention, pelvic, urological,
  inguinal or rectal surgery
• Study 1719 patients, 30 at risk of retention and
  unable to void at time of discharge
• 3 require catherization

19

• Even patients at risk of retention need not to
  void prior to discharge

20
Is it compulsory for patients to tolerate oral
fluids prior to discharge?
21

• Study 726 adult patients determined whether
  with-holding oral-fluids before discharge would
  decrease the incidence of PONV and shorten
  discharge time
• No difference in PONV
• Patients in the mandatory drinking group require
  greater time to ambulate, to void, and delayed
  discharge

22

• The Childrens Hospital of Philadelphia
• Sample size 20,000 children
• In pediatric surgery, the requirement to drink
  resulted in 50 increase in incidence of PONV
• The ability to tolerate oral fluids should not be
  a criteria for discharge

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What can be done to decrease the rate of
Post-operative nausea and vomiting ?
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• PONV is one of the leading reasons for delayed
  discharge and unanticipated admissions
• Chelsea and Westminster Hospital, London, UK
• Incidence 25-30
• 1/3 patients experience PONV at home even though
  they had no symptoms in hospital

25

• Gastric distension associated with mask
  ventilation
• Decompression may reduce the incidence
• Propofol
• N2O 4 meta-analyses shown a reduction in PONV
  without use
• Neostigmine
• Opiates
• Prophylactic antiemetics should be given to all
  high risk patients

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How can we achieve effective analgesia without
delaying discharge ?
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• Analgesia for ambulatory surgery effective yet
  simple to be transported home and continued for
  the recovery period
• Opiate-based analgesia has prevailed but can
  delay discharge due to increased PONV, sedation,
  ventilatory depression and difficulty voiding
• Multimodal balanced approach to analgesia

28

• Local anesthetic infiltration into wounds,
  joints, and neuroaxially is widely used as
  adjuvant to GA
• NSAID use is pivotal in ambulatory analgesia with
  effects to decrease peripheral and central
  responses to noxious stimuli

29

• COX-2 inhibitor decrease bleeding, GI and renal
  adverse effects of NSAIDs
• Postop rofecoxib 50mg
• celecoxib 200mg
• Paracetamol oral, rectal
• 35mg/kg provides as effective analgesia as
  1mg/kg of iv ketorolac in children after
  tonsillectomy
• Parecoxib, propacetamol (iv)