POSTOPERATIVE RECOVERY: Accompanied Overnight? - TOP

It is generally accepted that patients should be accompanied by an adult when they are discharged home from ambulatory surgery, but does anyone have any policies about requiring someone to actually stay with the patient overnight after their ambulatory surgery?

-- Anonymous

REPLY:

This is an excellent question, for which there is no simple answer. Unfortunately, there are no anesthesia or surgical organizations I am aware of who have published guidelines, practice parameters and/or policies regarding this topic. As well, there are no studies in the literature which specifically address this issue.

I believe the main concerns regarding having a patient spend the night alone after their surgery are: 1. will the patient be able to identify and obtain help for any postoperative problems which require urgent medical attention (eg. bleeding, uncontrollable nausea and vomiting…) ?; 2. will the patient be able to perform the necessary functions of daily living (eg. obtaining food and drink, using the toilet…) and/or manage his/her underlying medical conditions (eg. diabetes) despite potential limitations imposed by the anesthesia and/or surgery? Whether these concerns become actual problems will depend on a variety of factors, including the magnitude of the surgery, body area(s) effected by the surgery, type of anesthetic, underlying functional capacity (mental and physical) of the patient, and the presence of underlying medical conditions requiring special attention (such as diabetes with the need for blood glucose monitoring and insulin adjustments). On one extreme will be the young healthy adult having minimal sedation for very minor surgery, and on the other extreme will be the elderly patient with multiple medical problems who is barely able to function independently at the best of times and who has had one of the more invasive procedures which is "pushing the limit" for ambulatory surgery.

In the absence of guidelines from professional organizations or the literature, it is necessary for each institution to examine their patient populations to determine whether they should consider requiring a responsible adult to remain with the patient overnight on the day of surgery, either on a selective and/or universal basis. Unlike the requirement for patients to be discharged home accompanied by a responsible person, this stay-overnight requirement is not directly enforceable. However, proper patient education and early preoperative identification of those who will require this overnight care should aid considerably in maximizing cooperation with such policies.

-- From D. Daley, M.D., Houston, TX

 

POSTOPERATIVE RECOVERY: Gender - TOP

Does anyone know of any studies examining whether gender influences recovery
after ambulatory surgery under general anesthesia?

-- From Danilo Soto, Puerto Ordaz, Venezuela

REPLY:

I am not aware of any studies which have directly examined the influence of gender on recovery from general anesthesia in ambulatory surgery patients. One study of inpatients has shown that women emerge faster than men from general anesthesia with inhalational anesthetic agents (Myles PS et al, BMJ 2001;322:710-1). Another, which did not indicate the inpatient/outpatient status of their subjects, showed that women also emerge faster after general anesthesia with propofol/alfentanil/nitrous oxide (Gan TJ et al, Anesthesiology 1999;90:1283-7). The authors of these studies suggested that these findings may be due to women being less sensitive to the sedating effects of propofol, more rapid clearance of propofol in women than men, and/or hormonally-regulated functional changes in the γ -aminobutyric acid receptor (which is the site of action of most intravenous anesthetic agents).

Despite these differences in speed of emergence, gender has not been demonstrated to influence discharge time. Although I know of no studies which have specifically involved outpatients, two studies of inpatients and one study in which the inpatient/outpatient status of the subjects was not indicated, all demonstrated similar PACU discharge times for women and men (Myles PS et al, BMJ 2001;322:710-1; Waddle JP et al, Anesth Analg 1998;87:628-33; Taenzer AH et al, Anesthesiology 2000;93:670-5). These findings may be attributable to a higher rate of complications in women, which delay discharge from the PACU. For example, nausea and/or vomiting in the PACU are well known to occur more frequently in women than men, and hypertension in the PACU has also been demonstrated to occur more frequently in women (Rose DK et al, Anesthesiology 1996;84:772-81). Failure to find an effect of gender on PACU discharge may also reflect the predominance of other factors effecting time of discharge, particularly institutional system factors.

-- From D. Daley, M.D., Houston, TX

POSTOPERATIVE RECOVERY: Criteria-Based Discharge Phone Call Processes - TOP

Do any ambulatory surgery sites have criteria-based discharge phone call processes? We are currently attempting contact with 100%, reaching only 60% of patients.

-- From Christine Barrett

REPLY:

The scope of ambulatory surgery is evolving. Newer minimally invasive techniques continue to allow us to perform procedures in lesser intensity facilities with faster recovery. We need information on our patient’s well being quickly so that we can assess our programs and make continual improvements. Additionally our patients will appreciate the caring reassurance that a timely follow-up provides.

We should make every effort to call our patients post-operatively quickly. Given these great goals, getting call backs done successfully is a fine art.

I surveyed several of our units including outpatients processed in our large hospital based surgery units as well as two free standing surgery centers. Additionally we asked about a system that requires contacting patients for expedited appointments.

The hospital based unit performed at about the 50-60% rate. What we found was that they were using intake forms that did not have space for updating contact information. Subsequent calls were made using phone numbers stored in the main admitting system. We are modifying this approach but due to the lag time to change forms I don’t expect immediate improvement.

An additional problem that we encounter is not contacting the patient directly or with answering machines. Many patients having cosmetic procedures want this information guarded closely. This preference in combination with HIPPA guidelines have limited our aggressiveness of tracking down individuals.

Happily, our free standing surgery centers have had excellent (95+ %) success. Both centers ask for a contact number (cell, home, hotel, etc.) when they are giving discharge instructions. They inform the patients and their responsible adult that they will be called the next day. One of the nurses compares the discharge sheets to the surgical schedule to ensure that no one is missed. Also if they cannot contact the patient on day one they try again the following day.

One of our departments has a system for rapidly returning results for expedited appointments. When the patient cannot receive an appointment directly on the first phone contact, they are guaranteed a phone call within 24 hours. Patients have been very happy and with their motivation to get an appointment, usually give good contact options.

We have also used standardized scripts when we interview patients. By planting an encouraging word during our evaluation, we have seen definite improvements in our patient satisfaction results.

We need to continue to define our patients concerns, be they nausea and vomiting, pain, or scheduling problems to name a few. The only way we can make improvements is to find out this information. Based on our experience, finding an honest contact number prior to discharge is the most likely to yield results.

-- From Robert Helfand, M.D., Cleveland, OH

POSTOPERATIVE NAUSEA AND VOMITING - TOP

I am the Director of Nursing in a free standing surgery center. We had an increase of post-op nausea and vomiting (PONV). Calculated out there was 10% of the patients having postoperative PONV. It has since decreased to 6.25%. Are these numbers within normal range for PONV? We do general surgery, ENT, podiatry, and plastics.

-- From Cathy Smith, R.N., B.S.N.

REPLY:

The postoperative nausea and vomiting (PONV) rate in a free-standing surgery center will depend not only on the type of surgical procedure but on the anesthetic regimen and on a number of preoperative clinical risk factors. There are literally thousands of clinical studies in this area. From these studies among the most commonly cited factors that predict PONV are female gender, young age, previous history of PONV, and use of narcotics. A rate of 6.25 to 10% on the face of it does not appear excessive. Rates as high as 30% or more are noted in the literature for certain surgical procedure and high risk groups.

Another point worth noting is that PONV is not a binary outcome. Nausea, and vomiting, will vary in severity. Furthermore, antiemetic agents differ in their ability to prevent nausea, compared with prevention of vomiting. To define this more carefully, nausea and vomiting scores, similar to those used for the quantification of pain, are in use in some centers.

Although reduction of PONV is, because of its unpleasantness, a worthy objective for any outpatient surgery center, keep in mind that PONV is only an intermediary outcome. To assess whether your rate is inappropriately high, check whether PONV is itself leading to a significant number of unexpected admissions, delayed discharge from the facility, or patient dissatisfaction with perioperative care. If that is the case then it is probably worthwhile dissecting out the cause for a higher PONV rate and focusing on preventive and therapeutic measures. By applying multimodal interventions, including multiple antiemetic agents, adequate hydration, propofol-based anesthesia, avoidance of narcotic analgesics and nitrous oxide, the PONV rate can be reduced to very low levels (Scuderi. Anesthesiology 1999;90:360-371)

-- From Gary Kantor, M.D., Cleveland, OH

POSTOPERATIVE ANALGESIA: Cox-2 Inhibitors - TOP

Cox-2 inhibitors , such as Celebrex (celecoxib), and Bextra (valdecoxib) are now very popular. They are touted for their safety profile, with reduced, if not absent, anti-platelet, renal and GI side effects.

Nevertheless, some of our surgeons are nervous about patients continuing to take these agents preoperatively. Have we reached the stage where we can safely instruct our patients to take their Cox-2 inhibitors on the day of surgery before coming to the ambulatory surgery facility? Or should we continue the traditional practice that was prevalent with standard NSAIDs, of advising that patients discontinue their Cox-2 drugs for some period before surgery?

-- From Gary Kantor, M.D., Cleveland, OH

REPLY:

The selective COX-2 inhibitors (celecoxib and valdecoxib), a new group of anti-inflammatory and analgesic drugs, were developed to avoid some of the side effects associated with traditional nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs). The selective COX-2 inhibitors appear have similar analgesic efficacy as the nonspecific NSAIDs; however, they do not affect platelet function and reduce the risk of gastrointestinal ulceration. Of note, the cardiovascular and renal effects of selective COX-2 inhibitors remain controversial. It is suggested the cardio-renal effects of selective COX-2 inhibitors are similar to that of nonspecific NSAIDs. Rofecoxib was recently withdrawn from the market because it has a higher incidence of cardiovascular adverse effects.

Because the selective COX-2 inhibitors do not affect platelet aggregation and thus do not affect perioperative bleeding, they can be safely administered preoperatively. However, one of the major concerns with the perioperative use of selective COX-2 inhibitors is the associated risk of delayed bone and ligament healing. This is one of the reasons many orthopedic surgeons are reluctant to use selective COX-2 inhibitors for surgical procedures in which delayed bone healing is a concern. However, the effects of selective COX-2 inhibitors on bone and ligament healing remain controversial as there is no good clinical study available.

In summary, selective COX-2 inhibitors need not be discontinued prior to surgery (unless if there is concern of delayed bone and ligament healing). In fact, the doses may have to be increased preoperatively to achieve superior postoperative pain relief (e.g., if the patient is on celecoxib 200 mg per day it needs to be increased to 400 mg preop). In addition, they need to be administered on a regular "round-the-clock" basis with, opioids used as "rescue" analgesics on an "as needed" basis. Furthermore, combination of selective COX-2 inhibitors with local anesthetic techniques provides superior pain relief. Based on numerous publications, the doses for celecoxib are 400 mg preoperatively followed by 200 mg twice daily, and valdecoxib 40 mg preoperatively followed by 20 mg twice daily. Because both nonspecific NSAIDs and selective COX-2 inhibitors act by inhibiting the COX-2 isoenzyme, it is imperative that the two groups of drugs are not administered simultaneously. For example, if the patient has received a selective COX-2 inhibitor preoperatively, it is not necessary to administer ketorolac intraoperatively.

-- From Girish Joshi, M.D., Dallas, TX

POSTOPERATIVE ANALGESIA: Toradol - TOP

Does anyone advocate the use of Toradol in children for dental rehab? It seems to me that children are calmer on wake-up when it is used. They don't seem as wild on wake-up and don't require that extra dose of narcotic to settle them down.

-- From Debra Tyler, M.D., Dallas, TX

REPLY:

Obviously, better pain control is good for everyone. However, there are a couple of studies showing that children have a smoother emergence when given a narcotic. I don't know if this is because of something good about narcotics (such as decreased cough reflex or just being stoned), or just better pain control. If the kids are old enough, why not use a COX-2 agent orally rather than one that might inhibit platelet function? I'd also check with the dentists to see if they have any thoughts on the platelet issue.

-- From Alan P. Marco, M.D., M.M.M., Toledo, OH

REPLY:

Unless there are specific contraindications to the administration of ketorolac, our group tries to make it a habit of administering 0.5 mg/kg of ketorolac as adjunct analgesic for pediatric dental cases. We perform 10-15 of those cases per week and have found ketorolac to be quite helpful. The oral surgery literature has a great wealth of information about NSAIDs and dental procedures. However, we do not use ketorolac in children less than 18 - 24 months of age due to its unknown affects upon the kidney.

-- From Andrew Herlich, D.M.D., M.D., Philadelphia, PA

POSTOPERATIVE ANALGESIA: Post-Operative Nerve Blocks - TOP

I received a letter from an insurance carrier, citing that my group's "heavy use of single injection post-operative nerve blocks for pain control....are not medically necessary". The reviewer noted: "Heavy use of single injection post-operative nerve blocks for pain control." The exact commentary follows: "This practice, while within the current standard of care, is controversial. While pain control is clearly medically necessary, it is usually satisfactorily provided with oral narcotics, ketorolac, and NSAIDS. Post-op nerve blocks can, at best, provide only a few hours of relief, and then other means for pain control must be utilized (e.g. Vicodin, etc.).  A better technique involves surgical insertion of a tiny catheter connected to a slow continuous infusion pump. These are quickly inserted (<1 minute) by the surgeon and provide relief for days to weeks....and have lower risk (inserted under direct vision by surgeon=no nerve trauma), and probably cost less....These blocks are not medically necessary". Does anyone have any comments regarding this?

-- Anonymous

REPLY:

If they state that this is standard of care, how can they claim it is not medically necessary? Also, the carrier needs some education on nerve blocks - they last more than a few hours with long acting agents. We frequently use blocks so that we can send the patient home instead of admitting for pain control/IV narcotics. The idea that surgeons can do this cheaper is not valid, because implanting a catheter will result in another fee- it won't be covered under the global fee for the procedure. Most importantly, there is little data showing head to head comparisons on blocks vs. indwelling catheters. There is also a cost in the elastomeric or other pumps ($200-300) that would be required for the catheter technique. Furthermore, there is considerable debate over the safety of sending patients home with these devices. While it may be OK, there is not a preponderance of evidence and there are increased risks (infection, broken catheters, etc.). So, in the absence of data showing that the indwelling catheter technique is better and the complete lack of savings in cost over a block, and admission that this is standard of care, there is no basis for saying that it is not medically necessary.

-- From Alan P. Marco, M.D., M.M.M., Toledo, Ohio

REPLY:

Having been a practitioner of regional anesthesia for outpatients since 1996, I find this degree of misinformation and undeserved authority by a claim reviewer/third party payer to be at the core of the potentially greatest problem in the health care system in the United States.

It is true that single-injection nerve blocks provide short-duration analgesia. This short duration can range from 6-8 hours (e.g., mepivacaine) to 12-16 hours (ropivacaine without additives) to 18-24 hours (ropivacaine with additives such as clonidine and buprenorphine). All of these time intervals allow patients to self-administer 1-2 doses of postoperative oral opioids (and other non-opioid analgesics, e.g., COX-2 inhibitors, which insurers also commonly refuse to pay for) before blocks resolve. Lower net doses of perioperative opioids are associated with less PONV and fewer unplanned hospital admissions (not to mention less somnolence, respiratory depression, constipation, urinary retention, and pruritis).

Centers that routinely perform peripheral nerve blocks in an effort to provide meaningful pain relief do so because their surgeons and patients want them. Most importantly, peripheral blocks have been demonstrated to be more effective and provide better patient-reported outcomes than using strictly opioid-based postoperative analgesia. Regional anesthesia practitioners routinely serve as consultants to the surgeon to provide optimal analgesic care to patients. Pain is not only an unpleasant symptom, but it is also a symptom that is associated with stress. In this respect, regional anesthesia techniques have been clearly demonstrated to be the techniques of choice to prevent the development of the postoperative stress syndrome. The potential predilection of patients with inadequately treated surgical pain to develop chronic pain syndromes cannot be underestimated.

The main reasons that more people are not using regional blocks routinely is that (i) many anesthesiologists are not appropriately trained in the performance of these techniques, and (ii) perhaps surgeons are unwilling to have updated pain management practices for their patients when anesthesiologists are indeed trained in regional techniques. Third parties refusing to pay for a value-adding service (as listed in the original question) should not be a rate-limiting step. Quality of care in medicine is as important as the care itself. It is outrageous that an insurance company can claim that having inadequate pain control (with oral opioids and NSAIDS) while being afflicted with GI (PONV, hemorrhage) and renal side effects, along with itching, urinary retention, constipation, and respiratory depression is equal to having a single-injection block for postoperative pain relief.

Wound/intra-articular catheters represent a technique potentially providing longer lasting pain relief. However, (i) the pain associated with a number of orthopedic procedures is of short duration and do not justify a long lasting technique, (ii) wound / intra-articular infusions of local anesthetics have been shown to be less effective than continuous nerve block techniques, and (iii) the use of wound / intra-articular infusions is associated with an increased risk of joint infections, which represent a rare but catastrophic complication.

Furthermore, for a third-party payer to declare that the risk for nerve damage from peripheral nerve blocks is prohibitive, as justification for withholding payment for the charge-modified anesthesiologists' billing, indeed calls into question the ethics of such third party payers. Third party payment systems' decision makers who adopt such a patient-unfriendly mindset (or policy) may wish to pray that neither they nor their family members get sick or injured, lest the insurance policy they so carefully crafted to minimize expenditures restricts the quality of care they or their loved ones receive.

-- From Brian A. Williams, M.D., M.B.A., Pittsburgh, PA, Jacques E. Chelly, M.D., Ph.D., M.B.A., Pittsburgh, PA, and John P. Williams, M.D., Pittsburgh, PA

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