SAMBA - Educational Content III

Practice Guidelines for Postanesthetic Care. (Approved by the House of Delegates on October 17, 2001): A Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. http://www.asahq.org/publicationsAndServices/postanes.pdf

Aldrete JA: The post-anesthesia recovery score revisited. J. Clin Anesth 7:89-91, 1995.

Apfelbaum JL: Bypassing the PACU: a cost-effective measure. Can J Anaesth 45(5 Pt 2):R91-4, 1998.

Apfelbaum JL et al. Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics. Anesthesiology. 97(1):66-74, 2002 Jul.

This report lists thorough, intuitive criteria, which when combined with the anesthesiologist’s approval, allowed patients to bypass the traditional recovery room. Emphasis is placed on the standardized use of a “short-acting, fast-emergence” general anesthetic technique. Of the 1136 GA patients followed using the reported criteria, 32% bypassed PACU.

Chung F: Recovery patterns and home readiness after ambulatory surgery. Anesth Analg 80:896-902, 1995.

Prospectively examined patient recovery patterns and home readiness. 500 patients were scored using the Postanesthetic Discharge Scoring System (PADSS). PADSS, in conjunction with a follow-up telephone interview, helped identify factors that delay discharge.

Chung F: Are discharge criteria changing? J Clin Anesth 5(Suppl 1):64S-68S, 1993.

This excellent review of complex issues surrounding discharge of ambulatory patients includes a successfully implemented postanesthesia discharge scoring system.

Marshall SI, Chung F: Discharge criteria and complications after ambulatory surgery. Anesth Analg 88:508-17, 1999.

A review article that addresses discharge criteria, as well as the types of occurrences that may delay discharge.

Watkins AC. White PF. Fast-tracking after ambulatory surgery. Journal of Perianesthesia Nursing. 16(6):379-87, 2001 Dec.(Review)

The fast-tracking recovery concept examines different paradigms for streamlining the postoperative recovery process. Fast-tracking anesthetic techniques allow suitable outpatients to be discharged earlier after ambulatory surgery. Outpatients are normally transferred from the OR to the PACU, followed by transfer to the Phase II step-down (day-surgery unit) before discharge home. With conventional fast-tracking, it is possible to bypass the PACU and take patients directly from the OR to the step-down unit if they meet specific criteria before leaving the OR. Alternatively, if the step-down unit is already functioning at maximum capacity, the PACU can be restructured to include a fast-track area, where appropriate patients are treated as if they had been admitted directly to the step-down unit. For these PACU fast-track patients, less monitoring is performed, a family member is permitted to be with the patient, and the patient is allowed to ambulate, change into street clothes, and be discharged home directly from the PACU without any time restrictions. Preliminary studies have shown that outpatients who are fast-tracked can be discharged home earlier without any increase in complications or side effects. Importantly, fast-tracking after ambulatory surgery does not seem to compromise patient satisfaction with the surgical experience.

White PF: Criteria for fast-tracking outpatients after ambulatory surgery. J Clin Anesth 11:789, 1999.

White PF, Song D: New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete’s scoring system. Anesthe Analg 88:1069-72, 1999.

This scoring system was designed to allow qualifying patients after GA to be directly routed to the phase II (step-down) recovery unit instead of the traditional postanesthesia care unit (PACU). Comparative fast-track eligibility rates are reported for 216 outpatients undergoing laparoscopic surgery receiving one of 3 standardized GA techniques. 22-64% were fast-track eligible using the modified Aldrete criteria, versus 18-48% using the authors’-proposed criteria. 22-29% of patients required parenteral nursing interventions for pain or PONV after being deemed fast-track eligible using the modified Aldrete criteria, versus only 7-10% requiring the same nursing interventions for the authors’-proposed criteria

White PF: Ambulatory anesthesia–fast tracking concepts. Anesth Analg Suppl:153-6, 1998.

An article that helps define the concept of fast tracking. The article also discusses the circumstances that justify fast tracking after ambulatory surgery.

Williams BA, et al: Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway technique of process efficiency and recovery profiles in ambulatory orthopedic surgery. J Clin Anesth 10:570-8, 1998.

500 patients undergoing ambulatory anterior cruciate ligament reconstruction were reviewed. Combined general–retgional, when compared to general alone, had increased material costs as well as increased turnover time. However, the patients with the combined technique showed improved recovery profiles and lower admission rates, they also required fewer postoperative nursing interventions. Patients that received epidural anesthesia alone had discharge outcomes similar to those for thepatients with the combined technique. PACU bypass (fast-tracking) was more likely in the regional anesthesia patients. Regional anesthesia for these procedures may have a significant role in improving effiency and outcomes.

Williams BA, et al. PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more p hase II nursing interventions. Anesthesiology 97(4):981-8, 2002 Oct.

This scoring system was designed to allow qualifying patients after GA, RA, or MAC to be directly routed to the phase II (step-down) recovery unit instead of the traditional postanesthesia care unit (PACU). PACU bypass rates are reported for outpatient lower extremity surgery using these criteria, including the extent to which PACU bypass was associated with (1) required nursing interventions in the step-down recovery unit, and (2) successful same-day discharge. 87% percent (778/894) of all patients bypassed PACU. Fewer unplanned admissions were required in patients who bypassed PACU. There were no reportable adverse events associated with or resulting from PACU bypass. (Editor’s note: The PACU bypass rate was 76% after GA, and 92% after “straight regional” techniques; this per-technique PACU-bypass breakdown was not listed in the manuscript but was calculated from the manuscript’s dataset).

PRACTICE GUIDELINES FOR POSTANESTHETIC CARE (Approved by the House of Delegates on October 17, 2001): A Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care http://www.asahq.org/publicationsAndServices/postanes.pdf

Aldrete JA. The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia 7(1) 89-91, 1995.

Apfelbaum JL et al. Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics. Anesthesiology. 97(1):66-74, 2002 Jul.

Watkins AC. White PF. Fast-tracking after ambulatory surgery. Journal of Perianesthesia Nursing. 16(6):379-87, 2001 Dec.(Review)

White PF. Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesthesia & Analgesia. 88(5):1069-72, 1999 May.

Williams BA, et al. PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions. Anesthesiology. 97(4):981-8, 2002 Oct.

3. PACU symptom management and anesthetic/analgesic/intraarticular technique - TOP

Parnass, SM, et al. Beneficial impact of epidural anesthesia on recovery after outpatient arthroscopy. Arthroscopy 9(1):91-95, 1993.

Among 260 patients (GA n=181, epidural n=79), in the epidural group, discharge times were shorter (159 versus 208 min), the incidence of pain was less (24.1% versus 49.7%), and the incidence of PONV was lower (8.9% versus 32%).

Sneyd JR, et al. A meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents. European Journal of Anaesthesiology. 15(4):433-45, 1998 Jul.

This meta-analysis showed that the use of propofol exclusively (with or without nitrous oxide) was associated with a 270% risk reduction in nausea, and a 370% risk reduction in vomiting, when compared with the use of volatile agents.

Soderlund A, et al. Analgesia following arthroscopy--a comparison of intra-articular morphine, pethidine, and fentanyl. Acta Anaesthesiologica Scandinavica. 41(1 Pt 1):6-11, 1997 Jan.

When comparing meperidine 10 mg, morphine 1 mg, and fentanyl 10 mcg given intraarticularly after outpatient knee arthroscopy, the meperidine patients trended toward improved pain relief at rest and with movement (P=0.06). (Editor’s comment: at this time, we are not aware of any other comparative studies using higher doses of each of the 3 listed drugs).

Soderlund A, et al. A comparison of 50, 100 and 200 mg of intra-articular pethidine during knee joint surgery, a controlled study with evidence for local demethylation to norpethidine. Pain. 80(1-2):229-38, 1999 Mar.

This study endorses the use of meperidine for intraarticular analgesia (at the 50 mg dose) or for surgical anesthesia for diagnostic arthroscopy (at the 100-200 mg doses). The 200 mg dose was associated with higher plasma levels and more side effects than the 100 mg dose.

Patients in the GA group had more pain in the PACU than the spinal group and a higher incidence of PACU analgesic use. Patients in the spinal group were able to drink and eat sooner than the GA group. The times to sit, walk, and void were similar. The length of PACU and ASU stay between the GA and spinal groups were similar. The incidence of sore throat was higher in the GA compared to the spinal group.

Yang LC, et al. Postoperative analgesia by intra-articular neostigmine in patients undergoing knee arthroscopy. Anesthesiology. 88(2):334-9, 1998 Feb.

This study shows that intraarticular neostigmine (0.5 mg) provides longer-duration intraarticular analgesia than does morphine 2 mg.

Postoperative pain management is particularly important in the ambulatory surgical patient, since pain represents a major cause of unplanned hospital admissions. Pain can also contribute to postoperative nausea and vomiting and delay ambulation. See Sections 2 and 3 above, also.

Aho MS, Erkola OA, Scheinin H, et al: Effect of intravenously administered dexmedetomidine on pain after laparoscopic tubal ligation. Anesth Analg 73:112-118, 1991.

Dexmedetomidine, 0.2 or 0.4 µg/kg IV, relieved pain and reduced opioid drug requirement but was accompanied by sedation and a high incidence of bradycardia

Anderson R, Krohg K: Pain as a major cause of postoperative nausea. Can Anaesth Soc J 23:3661, 1976.

One hundred four patients who underwent either upper or lower abdominal surgery were studied. Postoperatively 50% of these patients had both pain and nausea. Only 10% had nausea without pain. When these patients received pain medication, nausea and pain were relieved in 80%. Thus, the treatment of postoperative pain may resolve emetic symptoms.

Beauregard L, Pomp A, Choiniere M: Severity and impact of pain after day surgery. Can J Anaesth 45:293-6, 1998.

Predictors of pain severity were evaluated along with the quality of analgesic practices and patient satisfaction. The severity and duration of pain after ambulatory surgery should not be underestimated. While in the hospital, pain should be treated aggressively. Analgesia protocols as well as comprehensive patient education programs should be provided to optimize pain relief at hone.

Campbell WI : Analgesic side effects and minor surgery: Which analgesic for minor and day-case surgery? Br J Anaesth 64:617-620, 1990.

In this retrospective study of analgesic requirements in patients undergoing orthopedic or oral surgery, the overnight admission rate was 4 times greater for those who received perioperative opioids than for those who did not.

Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg 85:808-16, 1997.

Postoperative pain is a common reason for the delayed discharge and unanticipated hospital admission of ambulatory surgery patients. Body mass, duration of anesthesia, and certain types of surgery were predictors of pain in the PACU.

Claxton AR, McGuire G, Cruise C: Evaluation of morphine versus fentanyl for postoperative analgesia after ambulatory surgical procedures. Anesth Analg 84:509-14, 1997.

Adequate postoperative analgesia without side effects is necessary to facilitate early discharge of ambulatory surgery patients. There was no significant difference in the duration of stay in the PACU, the times to teach recovery milestones, or the time to fitness for discharge. Morphine provided a better quality of analgesia but was associated with an increased incidence of post-discharge nausea and vomiting.

Eriksson H, Tenhunen A, Kortilla K: Balanced analgesia improves recovery and outcome after outpatient tubal ligation. Acta Anaesth Scand 1996; 40: 151-155

The use of a balanced analgesic technique, involving fentanyl, NSAIDS, and local anaesthetics, resulted in lower pain scores, lower incidence of PONV, and more rapid discharge in patients undergoing laparoscopic tubal ligation.

Goldsmith DM, Safran C: Using te Web to reduce postoperative pain following ambulatory surgery. Proc AMIA Symp (1-2):780-4, 1999.

Patients who had access to pain management information through resources made available on the Internet reported significantly less pain during the postoperative period.

Jin F. Chung F. Multimodal analgesia for postoperative pain control. [Review, 166 refs] Journal of Clinical Anesthesia. 13(7):524-39, 2001 Nov.

Pain is one of the main postoperative adverse outcomes. Single analgesics, either opioid or nonsteroidal antiinflammatory drugs (NSAIDs), are not able to provide effective pain relief without side effects such as nausea, vomiting, sedation, or bleeding. A majority of double or single-blind studies investigating the use of NSAIDs and opioid analgesics with or without local anesthetic infiltration showed that patients experience lower pain scores, need fewer analgesics, and have a prolonged time to requiring analgesics after surgery. This review focuses on multimodal analgesia, which is currently recommended for effective postoperative pain control.

Joyce TH III, Kubicek MF, Skjonsby BS, Jones MM: Efficacy of transnasal butorphanol tartrate in postepisiotomy pain: a model to assess analgesia. Clin Ther 15:160, 1993

Butorphanol, in a newly released nasal spray for delivery, relieved pain after episiotomy and cesearean section.

Klein SM, et al. Thoracic paravertebral block for breast surgery. Anesthesia & Analgesia. 90(6):1402-5, 2000 Jun.

In this prospective trial of 60 patients undergoing outpatient breast surgery, verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h.

Michaloliakou C, Chung F, Sharma S: Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anaesth Analg 1996;82:44-51

The concomitant use of local anesthetic, nonsteroidal anti-inflammatory agents and opioids resulted in faster recovery and earlier discharge.

Morrison NA, Repka MX: Ketorolac versus acetaminophen or ibuprofen in controlling postoperative pain in patients with strabismus. Ophthalmology 101:915, 1994

The effects of intravenous ketorolac lasted longer than the effects of oral ibuprofen or aspirin.

Rosenblum M, Weller RS, Conard PL, Falvey EA, Gross JB: Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. Anesth Analg 73:255, 1991

Ibuprofen controlled postoperative pain, gave pain relief for a longer period than fentanyl, and was associated with less nausea and vomiting.

Tong D, Chung F: Postoperative pain control in ambulatory surgery. Surg Clin of North America 79:401-30, 1999.

Optimizing postoperative pain control is essential for further advancement in the field of ambulatory anesthesia. Multimodal analgesia provides superior pain relief with fewer side effects. Preoperative administration of analgesia decreases intraoperative and postoperative requirements. Portable analgesic delivery systems may provide to be the method of choice for future ambulatory surgery, postoperative pain management.

Westerling D: Postoperative recovery evaluated with a new, tactile scale (TaS) in children undergoing ophthalmic surgery. Pain 83:297-301, 1999.

After pediatric eye surgery, visual scales for recovery assessment are inadequate. A tactile scale was used to rate postoperative pain. After further validation this scale may be a useful tool for assessment of postoperative pain I nother situations as well.

Wong HY, Carpenter RL, Kopacz DJ, et al: A randomized, double-blind evaluation of ketorolac tromethamine for postoperative analgesia in ambulatory surgery patients. Anesthesiology 78:6,-14, 1993

Patients given ketorolac both intravenously in the PACU and then orally for up to six days postoperatively had less somnolence and earlier return of bowel function than those who received fentanyl in the PACU and codeine with aspirin afterwards.

Nausea and vomiting continue to be a major source of delayed discharge, unanticipated admission, as well as an important contributor to potential patient dissatisfaction. The treatment of nausea is primarily pharmacological. The older, less expensive agents may cause undesirable side effects, while the newer agents tend to be expensive for routine use in all patients. Identifying the subgroups at greatest risk for postoperative nausea and vomiting helps focus therapeutic efforts where they are of greatest benefit.

Alon E, Himmelseher S: Ondansetron in the treatment of postoperative vomiting: a randomized, double-blind comparison with droperidol and metoclopramide. Anesth Analg 75:561, 1992

An 8-mg dose of ondansetron was superior to droperidol, 1.25 mg, and metoclopramide, 10 mg. When metoclopramide, 20 mg, and hydroxyzine, 25 mg, were given to patients desiring treatment for nausea or vomiting, 58% were successfully treated; of those who were still vomiting, droperidol, 0.625-1.25 mg, was succesful in effectively treating 56%.

ASHP Therapeutic Guidelines on the Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving Chemotherapy or Radiation Therapy or Undergoing Surgery. American Journal of Health-System Pharmacy. 56(8):729-64, 1999 Apr 15.

Beattie WS, Lindblad T, Buckley DN, Forrest JB: The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 38:298, 1991.

A higher incidence of postoperative nausea and vomiting was reported in women who were within the first 8 days of their menstrual cycle (highest at day 5) compared to those who were in the last portion of their cycle. Droperidol did not appear to further reduce the incidence in the former group.

Bodner M, White PF: Antiemetic efficacy of ondansetron after outpatient laparoscopy. Anesth Analg 73:250-254, 1991.

Patients undergoing laparoscopic tubal ligation received either ondansetron or saline in the recovery room if they were nauseated. Of the ondansetron-treated patients, 49% experienced no subsequent emetic episodes and 43% required more antiemetic medication. By comparison, 86% of the placebo-treated patients required a rescue antiemetic. Of interest, 42% of the saline group which received the rescue combination (metoclopramide and hydroxyzine) required a second rescue medication. Thus, the efficacy of ondansetron in the recovery room was similar to that of metoclopramide plus hydroxyzine.

Borgeat A, et al. Subhypnotic doses of propofol possess direct antiemetic properties. Anesth Analg 74:539, 1992.

Propofol, 10 mg, prevented nausea, with an 81% success rate (compared to 35% with placebo) in the PACU. The antiemetic effect may be of limited duration, however

Borgeat A, et al. Postoperative nausea and vomiting in regional anesthesia: a review. [Review, 282 refs] Anesthesiology. 98(2):530-47, 2003 Feb.

An extensive review which calls for better evaluation of PONV as an endpoint in studies using regional anesthesia techniques.

Cepeda MS, et al: Incidence of nausea and vomiting in outpatients undergoing general anesthesia in relation to selection of intraoperative opioid. J Clin Anesth 8:324-8, 1996.

Opioid administration at the doses used during induction of anesthesia (nalbuphine .25 mg/kg, alfentanil 20µg/kg( does not increase postoperative nausea or vomiting.

Coloma M, et al. Dexamethasone in combination with dolasetron for prophylaxis in the ambulatory setting: effect on outcome after laparoscopic cholecystectomy. Anesthesiology. 96(6):1346-50, 2002 Jun.

Dexamethasone 4 mg added to dolasetron 12.5 mg was more efficacious than dolasteron alone.

Desilva PH, et al. The efficacy of prophylactic ondansetron, droperidol, perphenazine, and metoclopramide in the prevention of nausea and vomiting after major gynecologic surgery. Anesthesia & Analgesia. 81(1):139-43, 1995 Jul.

When comparing prophylactic perphenazine 5 mg with droperidol 1.25 mg, ondansetron 4 mg, metoclopramide 10 mg, and placebo (all single-agent antiemetic prophylaxis agents, no combinations), perphenazine and droperidol patients showed lower nausea scores (versus the other 3 groups), and perphenazine patients showed less somnolence and restlessness (1/57 and 0/57) versus droperidol (12/55 and 4/55, respectively). (Editor’s note: perphenazine is no longer available as an intravenous preparation, but is available as an oral premedicant).

Di Florio T: The use of midazolam for persistent postoperative nausea and vomiting. Anaesth Intensive Care 20:383, 1992.

Since anxiety may be associated with persistent nausea and vomiting, midazolam has also been used for treatment.

Domino KB, et al: Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: A meta-analysis. Anesth Analg 88:1370-9, 1999.

A meta-analysis based on over 50 studies concluded that ondansetron and droperidol were more effective than metochlopromide in reducing postoperating vomiting. The overall risk of adverse effects did not differ.

Du Pen S, Scuderi P, Wetchler B, et al : Ondansetron in the treatment of postoperative nausea and vomiting in ambulatory outpatients: a dose-comparative, stratified, multicentre study. Eur J Anaesthesiol. 9 (Suppl 6):55-62, 1992.

Ondansetron was effective in treating postoperative nausea and vomiting in 500 ambulatory patients. Of patients treated with ondansetron, 40-50% manifested a "complete response", i.e., no nausea, vomiting, or need for rescue medication; with placebo, a complete response was noted in 15%. The optimal dose of ondansetron was found to be 4 mg.

Eberhart LH, et al. Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting. Anaesthesia. 57(10):1022-7, 2002 Oct.

This article uses patient willingness-to-pay analysis to demonstrate the cost-effectiveness of multimodal anti-emetic prophylaxis.

Elhakim M, et al. Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy. Canadian Journal of Anaesthesia. 49(9):922-6, 2002 Nov.

Ferrari LR, Donlon JV: Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg 75:351, 1992.

Metoclopramide 0.15 mg/kg, given to children in the PACU after tonsillectomy significantly decreased the incidence of vomiting.

Frighetto L, et al: Cost-effectiveness of prophylactic dolasetron or droperidol vs. rescue therapy in the preventin of PONV in ambulatory gyncologic surgery. Can J Anaesth 46:536-43, 1999.

Based on costs of medical care in Canada, the difference between the two agents was small. Either drug used intraoperatively was more cost-effective than no prophylaxis in ambulatory gynecologic surgery.

Gan TJ et al: Patient-controlled antiemesis: a randomized, double-blind comparison of two doses of propofol versus placebo. Anesth 90:1564-70, 1990

Propofol is effective in managing PONV with shorter PACU stay and a great degree of patient satisfaction. As the group wit ha 40mg demand dose experienced 2 episodes of oversedation, the lower demand dose of 20 mg seems more appopriate.

Hammas B, et al. Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen--comparison with propofol or placebo. [Clinical Trial. Journal Article. Randomized Controlled Trial] Acta Anaesthesiologica Scandinavica. 46(3):232-7, 2002 Mar.

The 4-drug regimen was dexamethasone 4mg, ondansetron 4 mg, droperidol 1.25 mg, and metoclopramide 10 mg. PONV incidence was 24% in the treatment group, and 70% in the control group.

Kovac A, et al: Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomiting: a randomized, double-blind, placebo-controlled multicenter trial. J Clin Anesth 11:453-9, 1999.

When preoperative prophylaxis with ondansetron 4 mg i.v. is not successful, a repeat 4 mg dose in the PACU does not appear to offer additional control of PONV>

Kovac A, McKenzie R, O'Connor T, et al: Prophylactic intravenous ondansetron in female outpatients undergoing gynecological surgery: a multicentre dose-comparison study. Eur J Anaesthesiol 9 (Suppl 6):37-47, 1992.

In 580 patients undergoing ambulatory gynecologic surgery under general anesthesia, 1, 4, or 8 mg of ondansetron significantly reduced nausea and emesis scores during the 24-hour postoperative period without causing sedation. The optimal dose was 4 mg.

Larijani GE, Gratz I, Afshar M: Postoperative nystagmus and nausea. Ann Pharmacother 28:179-81, 1994.

Sixty-six patients recovering from general anesthesia following elective ambulatory surgeries were tested postoperatively for nystagmus and monitored for nausea and vomiting for the first postoperative day. The presence of nystagmus in early recovery was associated with a higher incidence of nausea and vomiting during the first postoperative day.

Larijani GE, Gratz I, Afshar M, Minassian S: Treatment of postoperative nausea and vomiting with ondansetron: A randomized, double-blind comparison with placebo. Anesth Analg 73:246-249, 1991.

Ondansetron was effective as an antiemetic in 78% of patients compared to a 28% effectiveness of placebo.

Lim BS, Pavy TJ, Lumsden G: The antiemetic nad dysphoric effects of droperidol in the day surgery patient. Anaesth Intensive Care 27:371-4, 1999.

The incidence of side effects of droperidol 10µg/kg vs 20µg/kg were compared. Incidences of anxiety, restlessness, and dysphoric reactions were similar in both groups. Nor was there a significant difference in PONV scores. There was a significantly higher incidence of pain in the lower dose group. The study concludes that there is no advantage in lowering the dose of droperidol below 20µg/kg in ambulatory surgical patietns.

McKenzie R, Kovac A, O'Connor T, et al : Comparison of ondansetron versus placebo to prevent postoperative nausea and vomiting in women undergoing ambulatory gynecologic surgery. Anesthesiology. 78:21-8, 1993.

In 544 patients undergoing ambulatory gynecologic surgery, ondansetron (1, 4, and 8 mg) was significantly more effective (62%, 76%, and 77%, respectively) than placebo (46%) in preventing vomiting.

Melnick BM: Extrapyramidal reactions to low-dose droperidol. Anesthesiology 69:424-426, 1988.

Two case reports demonstrate that extrapyramidal effects can occur following low-dose droperidol. In both cases, symptoms developed relatively late in the postanesthetic recovery.

Montgomery JE, Sutherland CJ, Kestin IG, Sneyd JR:. Infusions of subhypnotic doses of propofol for the prevention of postoperative nausea and vomiting. Anaesthesia 1996 51:554-557

Pearman MH: Single dose intravenous ondansetron in the prevention of postoperative nausea and vomiting. Anaesthesia. 49 (Suppl:)11-5, 1994.

In 4,637 patients, ondansetron reduced the incidence of nausea and vomiting more than placebo. Doses of 4 and 8 mg were superior to a 1-mg dose.

Scuderi PE , et al: Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic tratment. Anesthesiology 90:360-71, 1999.

575 adults, scheduled for outpatient general anesthesia were randomized to receive either a 4 mg dose of ondansetron or a placebo. No differences occurred in the time to discharge, rate of unexpected admissions, or time to return to normal activity between the prophylaxis and treatment groups.

Scuderi PE . Droperidol: many questions, few answers. [Editorial] Anesthesiology. 98(2):289-90, 2003 Feb.

Despite the long-term documented efficacy of droperidol, the recent FDA “black-box” warning, although probably unjustified in the practice of anesthesiology, has made the commonplace use of droperidol less widespread than previously.

Scuderi PE, D’Angelo R, Harris L, Mims GR, et al: Small dose propofol by continuous infusion does not prevent postoperative vomiting in females undergoing outpatient laparoscopy. Anesth Analg 1997;84:71-5

Scuderi P, Wetchler B, Sung YF, et al: Treatment of postoperative nausea and vomiting after outpatient surgery with the 5-HT3 antagonist ondansetron. Anesthesiology. 78:15-20, 1993.

In 500 ambulatory patients (447 female) undergoing general anesthesia, all doses of ondansetron were superior to placebo. Doses of 1, 4, and 8 mg were 57%,61%, and 57% effective respectively, in preventing nausea or vomiting; vomiting was prevented in 30% following treatment with placebo.

Shenkman Z, et al: Acupressure–acupunctione antiemetic prophylaxis in children undergoing tonsillectomy. Anesthesiology 90:1311-16, 1999.

Perioperative acupressure and acumpuncture did not lessen emesis in chidlren after tonsillectomy.

Sinclair DR, Chung F, Mexei GL: Can postoperative nausea and vomiting be predicted? Anestehsiology 91:109-18, 19999.

Knowing the factors that predict PONV will help determine which patients will benefit most from antiemetic therapy. Age, sex, smoking status, previous PONV, type of anesthesia, duration of anesthesia, and type of surgery were all independent predictors o nPONV.

Tang J, et al: The effect of timing of ondansetron administration on its efficacy, cost-effectiveness, and cost-benefit as a prophylatic antiemetic in the ambulatory setting. Anesth Analg 88:1191-2, 1999.

Ondansetron 4 mg i.v. was most efficacious in preventing PONV when administered immediately before the end of surgery.

Tang J, Watcha MF, White PF: A comparison of costs and efficiency of Ondansetron and Droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures. Anesth Analg 1996; 83:304-13.

In a direct comparison, 0.625mg droperidol is found to be as effective an antiemetic as 4mg of ondansetron. It is also found that droperidol is more cost effective.

Tramer MR, et al: Cost-effectiveness of ondansetron for postoperative nausea nad vomiting. Anaesthesia 54:226-3, 1999.

The prophylactic dose of ondansetron (4-8mg), as determined y meta-analysis was compared to the meta-analysis derived dose for treatment (1-4mg). Fewer patients experience any PONV symptoms with prophylaxis compared with treatment. However, prophylaxis is only slightly more effective than treatment. Therefore, on the basis of cost-effectiveness, a decision could be made to not prophylax, but rather wait to treat PONV>

Wang JJ, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in females undergoing thyroidectomy: a dose-ranging study. Anesthesia & Analgesia. 91(6):1404-7, 2000 Dec.

Dexamethasone 5 mg IV is the minimum effective dose in preventing postoperative nausea and vomiting in women undergoing thyroidectomy.

Warrick PD, Belo SE: Treating “rebound” emesis following outpatient gynecologic laparoscopy: the efficacy of a two-dose regimen of droperidol and ondansetron. J Clin Anesth 11:119-25, 1999.

The findings suggest that prophylactic combined with two-dose ondansetron and droperidol offers no added benefit over single-dose therapy for routine use in the gynecological outpatient population.

Watcha MF, White PF: Postoperative Nausea and Vomiting - Its etiology, treatment, and prevention Anesthesiology 77:162-184, 1992.

A comprehensive review (262 refs) which covers all aspects of PONV, include etiology, anaesthetic factors and management.

Zestos MM, Carr AS, Mcauliffe G, Smith HS, et al: Subhypnotic propofol does not treat postoperative vomiting in children after adenotonsillectomy Can JAnaesth 1997; 44:4:401-404

A trio of studies which cast doubt on the alleged direct anti-emetic properties of propofol.

Anonymous. Reversal of the central effects of midazolam by intravenous flumazenil after general anesthesia in outpatients premedicated with an opioid and a muscle relaxant: report of a multicenter double- blind clinical study. The Flumazenil in General Anesthesia in Outpatients Study Group II. Clin Ther 14:954- 65, 1992.

Flumazenil was studied in 172 outpatients. Seventy-six percent of those alert at 5 minutes maintained their level of wakefulness throughout the 180- minute observation period. Fifty percent of flumazenil- treated patients and 31% of 59 placebo- treated patients reported one or more adverse experiences such as nausea, vomiting, and dizziness.

Reversal of benzodiazepine-induced sedation by flumazenil should not replace appropriate ventilatory assistance and, if necessary, placement of an endotracheal tube.

Chollet-Rivier M, Ravussin P: Midazolam- flumazenil vs. propofol in ambulatory ENT endoscopic procedures. Eur J Anaesthesiol 9:377- 85, 1992.

Eighty ambulatory patients undergoing ENT endoscopic procedures received either midazolam- flumazenil or propofol. Early recovery was faster with midazolam- flumazenil, and hemodynamic stability was better in patients with poor cardiovascular risk. With propofol, street- fitness was more rapidly obtained, and hemodynamic stability was better in patients without cardiovascular disease.

Ghouri AF, et al. Effect of flumazenil on recovery after midazolam and propofol sedation. Anesthesiology 81:333- 9, 1994.

Ninety- nine women undergoing breast biopsies under local anesthesia eceived either propofol- placebo; midazolam- placebo; or midazolam- flumazenil. Early recovery with midazolam sedation and flumazenil reversal was similar to recovery after propofol sedation. However, the beneficial effects of flumazenil were apparent only during the first 60 min after the procedure. Re-sedation remains an important consideration in outpatients.

Kestin IG, et al. Psychomotor recovery after three methods of sedation during spinal anaesthesia. Br J Anaesth 64:675, 1990

After one hour there was usually no difference in psychomotor performance from control.

Philip BK, et al. Flumazenil reverses sedation after midazolam-induced general anesthesia in ambulatory surgery patients. Anesth Analg 71:371-376, 1990.

Flumazenil can reverse the sedative, anxiolytic, and respiratory depressant effects of benzodazepines but did not fully do so in the doses given. The half-life of flumazenil is 1 hour; midazolam has a half life of 2.5 hours. By 120 to 180 minutes after administration, there was no longer a difference between the study and control groups.

Sanders LD, et al. Reversal of benzodiazepine sedation with the antagonist flumazenil. Br J Anaesth 66:445, 1991

Bailey PL et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 73:826-830, 1990.

This study investigated the respiratory effects of midazolam and fentanyl in human volunteers. Of note, midazolam and fentanyl in combination increased the risk of hypoxemia and apnea but did not depress the ventilatory response to CO2 more than did fentanyl alone. The data are relevant for anyone administering midazolam and fentanyl for conscious sedation.

Chripko D, et al. Decreases in arterial oxygen saturation in paediatric outpatients during transfer to the postanaesthetic recovery room. Can J Anaesth 36:128-132, 1989.

The decision to transfer patients from the operating room to the recovery room was made either clinically (Group I) or when the oxygen saturation was >98%, the end-tidal nitrous oxide concentration was <10% and CO2 concentration was <45 mm Hg (Group II). During transport to the recovery room, 27% of the patients in Group I had oxygen saturations < 90% compared to 8% in Group II. The article supports the use of additional criteria for the decision to transport patients to the recovery room. The article also shows why oxygen should be used during transfer of a patient from the operating room to the recovery room.

Morris RW, et al. The prevalence of hypoxemia detected by pulse oximetry during recovery from anesthesia. J Clin Monit 4:16-20, 1988.

Oxygen and pulse oximetry should be used in recovery rooms. Fourteen percent of inpatients had at least one hypoxic episode postoperatively. Obese patients, those undergoing body cavity procedures, those older than 40 years, those with ASA physical status above 3, those anesthetized for more than 90 minutes, and those who received more than 1500 ml fluid had a greater chance of developing hypoxemia.

Arvidson S, et al: Predicting postoperative adverse events. Clinical efficiencies of four general classification systems. The project perioperative risk. Acta Anaesthesiol Scand 40:783-91, 1996.

A prospective clinical-epidemiological study to help identify the factors that affect the perioperative risk in unselected adult patients undergoing elective general or orthopedic surgery.

Bailey PL, Pace NL, Ashburn MA, Moll JWB, East KA, Stanley TH: Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 73:826-830, 1990.

This study investigated the respiratory effects of midazolam and fentanyl in human volunteers. Of note, "midazolam and fentanyl in combination increased the risk of hypoxemia and apnea but did not depress the ventilatory response to CO 2 more than did fentanyl alone." The data are relevant for anyone administering midazolam and fentanyl for conscious sedation.

Chripko D, Bevan JC, Archer DP, Bherer N: Decreases in arterial oxygen saturation in paediatric outpatients during transfer to the postanaesthetic recovery room. Can J Anaesth 36:128-132, 1989.

The decision to transfer patients from the operating room to the recovery room was made either clinically (Group I) or when the oxygen saturation was >98%, the end-tidal nitrous oxide concentration was <10% and CO 2 concentration was <45 mm Hg (Group II). During transport to the recovery room, 27% of the patients in Group I had oxygen saturations < 90% compared to 8% in Group II. The article supports the use of additional criteria for the decision to transport patients to the recovery room. The article also shows why oxygen should be used during transfer of a patient from the operating room to the recovery room.

Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth 46:309-21, 1999.

This study examiend whether ambulatory surgery carries a higher risk for the elderly than for younger patients. The results showed that while the risks in the elderly do not constitute a contraindication, this population may require more careful cardiovascular management.

Duncan PG, et al. The Candadian four-center study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 39(5 Pt 1):440-8, 1992.

A study that examined over 6,900 atients that underwent surgery requiring general or regional anesthesia. They concluded that ambulatory surgery patients with preoperative medical conditions, even when optimally managed, are at higher risk for adverse events in the perioperative period.

Grazer FM, deJong RH: Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 105:436-48, 2000.

Reviews the statistics related to liposuction. The survey concludes that the late 1990s mortality rate from liposcution is about 20 per 100,000 as compared to the rate of U.S. motor vehicle accidents, 16.4 per 100,000. While unable to link deaths to specific reasons, liposuction is not an altogether benign procedure.

Hershey J, Valenciano C, Bookbinder M: Comparison of three rewarming methods in a post-anesthesia care unit. AORN Journal 65(3):597-601, 1997 Mar.

Postoperative hypothermia is problematic because patients in postanesthesia care units (PACUs) often feel very cold, and unrecognized or prolonged postoperative hypothermia can aggravate patients' underlying cardiovascular disorders. The researchers compared three methods of rewarming PACU patients who had undergone laparotomy procedures. Patients were assigned randomly to three groups. Each patient in group one received the standard PACU rewarming intervention (ie, two warmed thermal blankets and a hospital bedspread). Each patient in group two received the standard PACU rewarming intervention plus a reflective blanket. Each patient in group three received the standard PACU rewarming intervention plus a reflective blanket and a reflective head covering. Nurses measured patients' vital signs on admission to the PACU and every 15 minutes thereafter until patients' sublingual temperatures reached 36 degrees C (96.8 degrees F). No significant temperature differences occurred among patients in the three groups, but an inverse relationship existed between patients' PACU admission temperatures and the time they required to reach normothermia.

Marshall SI, Chung F: Discharge criteria and complications after ambulatory surgery. Anesth Analg 88:508-17, 1999

A review article that discusses potential complications after ambulatory surgery, and appropriate treatment regimens.

Morris RW, Buschman A, Warren DL, Philip JH, Raemer DB: The prevalence of hypoxemia detected by pulse oximetry during recovery from anesthesia. J Clin Monit 4:16-20, 1988.

Oxygen and pulse oximetry should be used in recovery rooms. Fourteen percent of inpatients had at least one hypoxic episode postoperatively. Obese patients, those undergoing body cavity procedures, those older than 40 years, those with ASA physcial status above 3, those anesthetized for more than 90 minutes, and those who received more than 1500 ml fluid had a greater chance of developing hypoxemia.

Petros JG, Rimm EB, Robillard RJ, Argy O: Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 161:431-433, 1991,

In a retrospective review of 295 men who underwent elective heniorrhaphy under spinal or general anesthesia, the prevalence of urinary retention was greater in patients older than 53 years who received general anesthesia and in whom perioperative fluid administration exceeded 1200 ml. The authors suggest that spinal anesthesia and minimizing the perioperative fluid may lessen the prevalence of postoperative urinary retention.

Please also refer to section B (Phase I Recovery, PACU) for reviews of Fast-Tracking, and Management of Pain and PONV.

1. Outpatient Regional Anesthesia: Long-duration single-injection nerve blocks, and indwelling nerve block catheters - TOP

Klein SM, et al. Major ambulatory surgery with continuous regional anesthesia and a disposable infusion pump. Anesthesiology. 91(2):563-5, 1999 Aug.

This and several other studies describe the usefulness of outpatient peripheral nerve block infusion pumps for analgesia.

Klein SM, et al. Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine. Anesthesia & Analgesia. 94(1):65-70, 2002 Jan.

This study demonstrates that long-acting peripheral nerve blockade may be safely used in the ambulatory setting with a high degree of efficacy and satisfaction. This technique is associated with an infrequent incidence of neurologic complications and injuries despite discharge with an insensate extremity. The frequent incidence of pain at 7 days suggests that longer-acting local anesthetics are still needed.

Mulroy MF, et al. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology. 97(2):315-9, 2002 Aug.

Using a threshold bladder ultrasound volume of 400 ml, these authors described successful same-day discharge of patients who had not voided with volumes below 400 ml. Shorter duration spinal and epidural anesthesia may allow return of bladder function before overdistention occurs in low-risk patients (those younger than age 70, not having hernia, rectal, or urologic surgery, and without a history of voiding difficulty).

Pavlin DJ. Pavlin EG. Fitzgibbon DR. Koerschgen ME. Plitt TM. Management of bladder function after outpatient surgery. Anesthesiology. 91(1):42-50, 1999 Jul.

This study was designed to test a treatment algorithm for management of bladder function after outpatient general or local anesthesia. Urinary retention affected 0.5% of low-risk non-pelvic surgery patients and none of the low-risk pelvic surgery patients. Median time to void after discharge was 75 min in low-risk non-pelvic surgery patients who were discharged without voiding. Fluids administered did not alter incidence of retention or time to void. In high-risk patients (anal surgery, herniorrhaphy, and history of retention), retention occurred in 5% of high-risk patients before discharge and recurred in 25% after discharge. CONCLUSION: In reliable patients at low risk for retention, voiding before discharge appears unnecessary. In high-risk patients, continued observation until the bladder is emptied is indicated to avoid prolonged overdistention of the bladder.

Petros JG, et al. Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 161:431-433, 1991.

Accreditation Manual for Hospitals. Oakbrook Terrace, Il, Joint Commission on Accreditation of Health Care Organizations (JCAHO), 1994.

A scoring system is described that can be used for discharge from phase two recovery to home.

Chung F. Mezei G. Factors contributing to a prolonged stay after ambulatory surgery. Anesthesia & Analgesia. 89(6):1352-9, 1999 Dec.

The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.

Jin F. Should adult patients drink fluids before discharge from ambulatory surgery? Anesthesia & Analgesia, 1998, August.

Korttila K. Recovery from outpatient anesthesia, factors affecting outcome. Anaesthesia 1995, 50(s) 22-28.

A comprehensive review of discharge criteria, and the influence that anesthetic techniques have on the timing of discharge.

Marshall SI. Chung F. Discharge criteria and complications after ambulatory surgery. [Review, 101 refs] Anesthesia & Analgesia. 88(3):508-17, 1999 Mar.

Pflug AE, Aasheim GM, Foster C: Sequence of return of neurological function and criteria for safe ambulation following subarachnoid block (spinal anaesthetic). Can Anaesth Soc J 25:133-139, 1978.

The sequence of return of somatic and sympathetic motor and sensory nerve function after subarachnoid block with tetracaine was evaluated. The sequence of return of neurologic activity is: sympathetic nervous system activity, pinprick sensation, somatic motor function, proprio-ception of the feet.

Phippen ML: Ambulatory surgery: recovery to discharge. Semin Perioper Nurs 1:249-54, 1992.

The nurse can use the nursing process to determine when a patient is ready for discharge from the ambulatory facility.

Schreiner MS, Nicolson SC, Martin T, Whitney L: Should children drink before discharge from day surgery? Anesthesiology 76:528, 1992

The ability to tolerate liquids before being discharged is often required. Yet when patients, 1-18 years of age, who were required to drink before being discharged were compared to those who were not, the former had a greater incidence of postoperative nausea and stayed 20 minutes longer in the hospital. Patients who were not required to drink were not readmitted because of dehydration.

Wetchler BV : Problem solving in the postanesthesia care unit. In Wetchler BV (ed): Anesthesia for Ambulatory Surgery, Philadelphia, JB Lippincott, 1985, p 375-436.

White, PF. Ambulatory Anesthesia—fast tracking concepts. Anesthesia & Analgesia, 1998 March.

White, P.F. New criteria for fast tracking after outpatient anesthesia: a comparison with the modified Aldrete scoring system. Anesthesia & Analgesia, 1999, May.

Dunn, D. Preoperative assessment criteria and patient teaching for ambulatory surgery patients. J. Perianesthesia Nursing, 1998, October.

Eddy ME, Coslow BI: Preparation for ambulatory surgery: A patient education program. J Post Anesth Nurs 6:5-12, 1991.

A PACU nurse can implement an instructional program and analyze outcomes. Patients must assume responsibility for their self-being and care. Education must focus on the patient's experiences.

Icenhour ML: Quality interpersonal care. A study of ambulatory surgery patients' perspectives. AORN J 47:1414-1419, 1988.

Good teaching can be done at the time of discharge, preferably with the family present. Health care personnel should not rely on written pamphlets, although they can be used. Ambulatory patients view caring and concerned nurses as better indicators of quality care than caring surgeons.

Jairath N, Campbell HM, Ahmad E, Chung F: Effective discharge preparation of elderly cataract day surgery patients. J Ophthalmic Nurs Technol 9:157-160, 1990.

Most elderly patient education can be done preoperatively. Some patients need later reinforcement.

Lea SG, Phippen ML: Client education in the ambulatory surgery setting. Semin Perioper Nurs 1:203-23, 1992.

This article discusses the purpose of client education, provides examples of teaching strategies for the ambulatory surgery setting, and describes the benefits of postoperative follow-up calls.

Patients who underwent outpatient surgery were surveyed to see what they did when they left the hospital. Thirty-one percent went home without a responsible adult, 73% of car owners drove within 24 hours of the operation, and 9% drove themselves home. One patient drove 15 miles home and then drove a busload of passengers 95 miles.

Stephenson ME: Discharge criteria in day surgery. J Adv Nurs 15:601-613, 1990.

A good overall summary of criteria is given for nurses to decide when a patient is ready for discharge after ambulatory surgery. Categories for the decision for discharge include mental state, mobility, pain, ability to eat and drink, elimination, information, and social factors.

Tong D. Chung F. Wong D. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology. 87(4):856-64, 1997 Oct.

Dissatisfaction with anesthesia is a predictor of global dissatisfaction with ambulatory surgery. An increasing number of symptoms 24 h after operation is a predictor of dissatisfaction with anesthesia. The rate of global dissatisfaction and anesthesia dissatisfaction is very low. The predictors from this model need to be validated by a second data set from either this or another center. Given the low rate of dissatisfaction, a focused study testing specific interventions to improve patient satisfaction would be difficult.

Zayas, L.E. Exploring instructional quality indicators in ambulatory medical ethnographic approach. Familay Medicine, 1999 October.

Chung F. Mezei G. Adverse outcomes in ambulatory anesthesia. [Review, 40 refs] Canadian Journal of Anaesthesia. 46(5 Pt 2):R18-34, 1999 May.

Jin F. Chung F. Minimizing perioperative adverse events in the elderly. [Review, 156 refs] British Journal of Anaesthesia. 87(4):608-24, 2001 Oct.

Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly.

Panarese, A. Early post-operative morbidity following tonsillectomy in children; implications for day surgery. J. Laryngol Otol, 1999, December.

Price SD, Hawkins DB, Kahlstrom EJ: Tonsil and adenoid surgery for airway obstruction: perioperative respiratory morbidity. Ear Nose Throat J 72:526-31, 1993.

Postoperative respiratory problems were the reason for prolonged hospital stay in 67% of patients undergoing T&A. Preoperative "danger-signals" of potential postoperative respiratory problems were a history of severe obstructive symptoms with apnea and moderate or strongly positive sleep study, daytime somnolence, need for urgent T&A, and cardiomegaly.

Schloss MD, Tan AK, Schloss B, Tewfik TL: Outpatient tonsillectomy and adenoidectomy: complications and recommendations. Int J Pediatr Otorhinolaryngol 30:115-22, 1994.

This article discusses issues relevant to tonsillectomy and adenoidectomy, and suggests that a triad, including recent history of upper airway infection, knife dissection technique, and intraoperative blood loss of 100 ml may predict the risk of postoperative hemorrhage.

Viitanen, H. Premedications with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesthesia & Analgesia, H1999, July.

Yardley MP: Tonsillectomy, adenoidectomy and adenotonsillectomy: are they safe day case procedures? J Laryngol Otol. 106(4):299-300, 1992.

A total of 3,488 tonsil and adenoid procedures yielded a hemorrhage rate of 0.49%, occurring predominantly within the first eight hours postoperatively.

Hogue, S.L. Assessing a tool to measure patient functional ability after outpatient surgery. Anesthesia & Analgesia, 2000 July.

Korttila K: Postanesthetic cognitive and psychomotor impairment. Int Anesthesiol Clin 24:59-74, 1986.

Computerized tests useful for psychomotor assessment of performance are described.

Manner T, Kanto J, Salonen M: Use of simple tests to determine the residual effects of the analgesic component of balanced anaesthesia. Br J Anaesth 59:978-982, 1987.

Patients received either fentanyl or buprenorphine as part of the analgesic component of a balanced anesthetic technique. The Maddox Wing and visual analogue scale sensitively differentiated between the postanesthetic residual effects of the two opioids. Critical flicker fusion was insensitive.

Myles PS et al.: Measurement of quality of recovery in 5672 patients after anaesthesia and surgery. Anaesthesia & Intensive Care. 28(3):276-80, 2000 Jun.

Myles PS et al. Validity and reliability of a postoperative quality of recovery score: the QoR-40. British Journal of Anaesthesia. 84(1):11-5, 2000 Jan.

Myles PS et al. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. British Journal of Anaesthesia. 84(1):6-10, 2000 Jan.

Myles PS et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesthesia & Analgesia. 88(1):83-90, 1999 Jan.

These 4 reports highlight the development and psychometric testing of the Quality of Recovery Score Assessments. There is a 9-item instrument and a 40-item instrument. The 9-item instrument is most well-suited for hospital-based assessment of anesthesia practice, whereas the 40-item instrument is most well-suited for the serial assessment of individual patients.

Sanders LD: Recovery of Psychological function after anaesthesia. Int. Anaesth. Clinics. 29:105-115, 1991.

Reviews the factors affecting recovery of psychomotor function following anaesthesia, and the tests which are used to measure psychomotor impairment

Smith JM, Misiak H: Critical flicker frequency (CFF) and psychotropic drugs in normal human subjects: A review. Psychopharmacologia 47:175-182, 1976.

This article provides a good review of studies that use the critical flicker frequency test. Pupil diameter and also other drugs such as caffeine and nicotine may affect results of this test.

D. Postoperative follow-up - TOP

Although major complications following ambulatory surgery are rare, seemingly "minor" complications occur with some frequency. These "minor complications" such as nausea and vomiting or urine retention pose important problems in the ambulatory setting. Not only are they distressing to the patient, but they impede patient discharge and disrupt patient flow. However, the nature of complications in the outpatient setting is subject to change, especially as patient selection criteria are liberalized. Therefore, data on complications need to be updated frequently, especially as we anesthetize more patients at the extremes of age and who have significant coexisting medical problems.

Chung F, Un V, Su J: Postoperative symptoms 24 hr. after ambulatory anaesthesia.Can J Anaesth 43:1121-1127, 1996.

1,017 patients were followed up after ambulatory surgery. At 24hrs the most common symptom was incisional pain, followed by headache and drowsiness. The incidence and type of complications suffered was related to the type of surgery.

Chung F: Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg 80:896-902, 1995.

This study showed that majority of patients are ready to be discharged within 2 hours after general anesthesia. Persistent symptoms such as pain, dizziness, nausea and vomiting would delay discharge. Escort not available is also one of the major reasons for delay in discharge.

Chung F, Lavelle PA, McDonald S, Chung A, McDonald NJ: Cognitive impairment after neurolept analgesia in cataract surgery. Anesth Analg 68:614-618, 1989.

This study showed that a small percentage of elderly patients with monitored anesthesia care and sedation undergoing cataract surgery suffered cognitive impairment at 6 h and 24 h postoperatively.

Duncan PG, Cohen MM, Tweed WA, et al: The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 39:440-8, 1992.

Adverse outcomes were examined in 6,914 adult (non-obstetrical) patients. Preoperative disease was predictive of some intraoperative events relating to the same organ system, but not to events in the PACU. Obese or inadequately fasted patients experienced a greater rate of recovery problems as well as discomfort.

Osborne GA, Rudkin GE: Outcome after day-care surgery in a major teaching hospital. Anaesth Intensive Care. 21:822-7, 1993.

Outcomes of 6000 procedures in a public teaching hospital-day surgery unit yielded an unanticipated hospital admission rate of 1.34%. Surgery-related admissions (0.95%) exceeded those related to anaesthesia (0.13%). Perioperative surgical complications (1:105) were more frequent than those related to anaesthesia (1:176) or pre-existing medical problems (1:500). Anaesthesia-related complications were more frequent with general (1:114) than with local plus sedation (1:780) or regional anesthesia (1:180). Seven percent of patients later presented to a local medical practitioner or hospital emergency service for minor problems.

Tong, D. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology, 1997. October.

Tong, D. Postoperative pain control in ambulatory surgery. Surgical Clinics of North America, 1999, April.

Tzabar Y, Asbury AJ, Millar K: Cognitive failures after general anaesthesia for day case surgery. BJA 76:194-197, 1996.

Warner MA, Shields SE, Chute CG: Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 270:1437-41, 1993.

Of 38,598 patients, ASA classes I-III, who underwent 45,090 ambulatory procedures and anesthetics, 33 patients either experienced major morbidity or died (1:1366). Four patients died (1:11,273), 2 of myocardial infarction and 2 in automobile accidents. More than one third of major morbidity occurred 48 hours or later after surgery. According to these data, one is more likely to die in an auto accident following ambulatory surgery than from the procedure itself.

Yogendran S, Asokumar B, Cheng DCH, Chung F: A prospective randomized double-blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery. Anesth Analg 80:682-686, 1995.

This study showed patients receiving 20 ml/kg of fluid had less nausea, less thirst, less dizziness and less drowsiness in PACU and ASU and 24 hours postoperatively.

Biswas TK, Leary C: Postoperative hospital admission from a day surgery unit: a seven-year retrospective survey. Anaesth Intensive Care 20:147-50, 1992.

A total of 18,321 outpatient procedures yielded 225 hospital admissions--a rate of 1.2%. The highest admission rate was found in gynecological surgery (45%), with laparoscopic procedures accounting for 64% of the gynecologic admissions. Urological admissions represented 4.5% of the urological caseload; 6% of admissions were for social reasons.

Campbell WI : Analgesic side effects and minor surgery: Which analgesic for minor and day-case surgery? Br J Anaesth 64:617-620, 1990.

A retrospective study of analgesic requirements in patients undergoing orthopedic or oral surgery. The overnight admission rate was 4 times greater for those who received perioperative opioids than for those who did not.

d’Errico, C. Prolonged recovery stay and unplanned admissions of the pediatric surgical outpatient: an observational study. J Clin Anesth, 1998, September.

Dresner SC, Klussman KG, Meyer DR, Linberg JV: Outpatient dacryocystorhinostomy. Ophthalmic Surg 22:222-224, 1991.

Records of all patients who had undergone outpatient dacryocystorhinostomy procedures over a 2-year period were studied. There were 14 hospital admissions on the day of surgery. Three of the patients were admitted for mild epistaxis; three were admitted for postoperative nausea, and three for social reasons.

Fancourt-Smith PF, Hornstein J, Jenkins LC: Hospital admissions from the Surgical Day Care Centre of Vancouver General Hospital 1977-1987. Can J Anaesth 37:699-704, 1990.

The principal reasons for surgery-related admissions were postoperative bleeding, complications, the need for further surgery, the requirement for prolonged postoperative care, and pain. Anesthesia-related admissions included "syncope," lack of an accompanying adult, aspiration pneumonitis, and coincident acute disease. Twelve of the 14 patients admitted with syncope underwent surgery in the afternoon and had received less than ideal amounts of IV fluid.

Fortier, J. Unanticipated admissions after ambulatory surgery—a prospective study.Can J Anaesth., 1998 July.

Gold BS, Kitz DS, Lecky JH, Neuhaus JM: Unanticipated admission to the hospital following ambulatory surgery. JAMA 262:3008-3010, 1989 .

This case control study identified risk factors for admission among 9,616 adult ambulatory surgery patients. The most common reasons for admission were vomiting, pain, and bleeding. Factors associated with an increased likelihood of admission were general anesthesia, postoperative vomiting, lower abdominal or urologic surgery, age, and length of procedure.

Isenberg SJ, Apt L, Yamada S: Overnight admission of outpatient strabismus patients. Ophthal Surg 21:540-543, 1990.

All patients over 15 months old who underwent outpatient strabismus surgery between July 1, 1987, and June 30, 1988, were studied. Of 303 patients, 24 (8%) were admitted. The most frequent reason for postoperative admission was nausea (38%) and the use of bilateral patches which prevented ambulation (16%).

Johnson CD, Jarrett PE: Admission to hospital after day-case surgery. Ann R Coll Surg Engl 72:225-228, 1990.

Hospital charts of patients who underwent outpatient surgery between 1983 and 1987 were examined. Seventy patients required admission. Before 1985 there were 12 admissions due to nausea, vomiting, or drowsiness after general anesthesia. After that time, when propofol was used, only 2 patients required admission for nausea, vomiting, or drowsiness.

Knoff SB, Van Sickels JE, Holmgreen WC: Outpatient orthognathic surgery: Criteria and a review of cases. J Oral Maxillofac Surg 49:117-120, 1991.

Fourteen of 87 patients required admission to the hospital. Length of surgery was a significant factor in determining which patients required admission. Reasons for admission included observation of the airway, severe nausea or vomiting, significant blood loss, and pain.

Mezei, G.Return hospital visits and hospital readmissions after ambulatory surgery. Ann Surg. 1999 November.

Patel RI, Hannallah RS: Anesthetic complications following pediatric ambulatory surgery: A 3-year study. Anesthesiology 69:1009-1012, 1988.

A survey of postanesthetic complications of 10,000 pediatric ambulatory surgery patients. The most common complications were vomiting, complications of surgery, and croup. The admission rate was 0.9%.

Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H: Factors affecting discharge time in adult outpatients. Anesthesia & Analgesia. 87(4):816-26, 1998 Oct.

Discharge time (total recovery time) is one determinant of the overall cost of outpatient surgery. We performed this study to determine what factors affect discharge time. Details regarding patients, anesthesia, surgery, and recovery were recorded prospectively for 1088 adult patients undergoing ambulatory surgery over an 8-mo period. The contribution of factors to variability in the discharge time was assessed by using multivariate linear regression analysis. In the last 4 mo of the study, nurses indicated the causes of discharge delays > or =50 min in Phase 1 or > or =70 min in Phase 2 recovery. When all anesthetic techniques were included, anesthetic technique was the most important determinant of discharge time (R2=0.10-0.15; P=0.001), followed by the Phase 2 nurse. After general anesthesia, the Phase 2 nurse was the most important factor (R2=0.13; P=0.01-0.001). In women, the choice of general anesthetic drugs was significant (R2=0.04; P=0.002). The three most common medical causes of delay were pain, drowsiness, and nausea/ vomiting. System factors were the foremost cause of Phase 2 delays (41%), with lack of immediate availability of an escort accounting for 53% of system-related delays. We conclude that efforts to shorten discharge time would best be directed at improving nursing efficiency; ensuring availability of an escort for the patient; and preventing postoperative pain, drowsiness, and emetic symptoms. The selection of anesthetic technique and anesthetic drug seems to be of selective importance in determining discharge time depending on patient gender and type of surgery. IMPLICATIONS: The relative importance of anesthetic and nonanesthetic factors were evaluated as determinants of discharge time after ambulatory surgery. Postoperative nursing care was the single most important factor after general anesthesia; anesthetic drugs, anesthetic technique, and preven-tion of pain and emetic symptoms were of selective importance depending on patient gender and type of surgery.

Seago JA, Weitz S, Walczak S: Factors influencing stay in the postanesthesia care unit: a prospective analysis. Journal of Clinical Anesthesia.10(7):579-87, 1998 Nov.

STUDY OBJECTIVE: To identify indicators of prolonged length of stay (LOS) in the postanesthesia care unit (PACU) and to test the following hypotheses: (1) that patient age, pain medication administration at the time of PACU admission, length of surgery, and cardiovascular, pulmonary, and pain responses postoperatively predict prolonged PACU LOS and (2) that cardiovascular and pulmonary symptoms preoperatively predict cardiovascular and pulmonary symptoms postoperatively. DESIGN: Prospective, observational analysis.

PATIENTS: 1,067 patients scheduled for surgery with general anesthesia between February and September 1996, 18 years of age or older.

MEASUREMENT AND MAIN RESULTS: 11.2% of the variation in prolonged PACU LOS can be predicted by age, pain medication at the time of PACU admission, and postoperative cardiovascular, pulmonary, and pain symptoms. A significant number of patients who did not report a prior history experienced postoperative cardiovascular and pulmonary symptoms. CONCLUSION: Patient history andpostoperative symptoms predict only a small percentage of prolonged PACU stays. Organizational factors may be a more important predictor of prolonged PACU stay. Additionally, assessment of cardiovascular and pulmonary history needs refinement to improve prediction of patient responses postoperatively.

Sibbritt DW: Readmissions of day-only patients in NSW acute hospitals. J Qual Clin Pract 14:31-8, 1994.

For several large Sydney hospitals, the percentage of patients readmitted was consistent across all lengths of stay (approximately 9%). When considering the types of admissions more suited to day surgery units, the readmission rate was 4.4%.

Smith R, Kolyn D, Pace R: Outpatient laparoscopic cholecystectomy. HPB Surg 7:261-264, 1994.

Outpatient laparoscopic cholecystectomy was performed in 98 patients, 37% of whom presented for elective cholecystectomy. Sixteen patients were admitted because of refractory nausea and vomiting in the early postoperative period, but 79 patients (81%) were discharged home within 4 to 6 hours of surgery.

Twersky R, Fishman D, Homel P: What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg 84:319-4, 1997.

A retrospective review of 6243 cases showed that 2.9% of patients returned to hospital, the most common reason was for surgical complications. Urological surgery was a significant predictor of return.

Chung, F. Factors contributing to a prolong stay after ambulatory surgery. Anesthesia & Analgesia 1999, December.

Although major complications following ambulatory surgery are rare, seemingly "minor" complications occur with some frequency. Not only are such problems distressing to the patient, but they impede patient discharge and disrupt patient flow. The nature of complications in the outpatient setting is subject to change, especially as patient selection criteria are liberalized. Therefore, data on complications data need to be updated frequently, especially as we care for more patients at the extremes of age, and with significant coexisting medical problems.

Clarke GA, Power KJ: Spinal anaesthesia for day-case surgery. Ann R Coll Surg Engl 70:144-146, 1988.

Fifty patients who underwent procedures suitable for spinal anesthesia were studied. Despite the use of a 26-gauge spinal needle, the incidence of spinal headache was 18%; in patients less 40 years old, the incidence was 39%. When these patients were compared with a group of control patients who received general anesthesia, the incidence of headache was higher in the spinal anesthesia group. This study supports the decision not to use spinal anesthesia in outpatients, particularly in the young.

Heath PJ, Ogg TW, Gilks WR: Recovery after day-case anaesthesia: A 24-hour comparison of recovery after thiopentone or propofol anaesthesia. Anaesthesia 45:911-915, 1990.

Sixty patients who underwent dilatation and curettage and who received either pentothal or propofol for induction or maintenance of anesthesia were studied. There was some evidence of memory function impairment 24 hours after anesthesia.

Hempenstall PD, de Plater RM: Minimal morbidity in outpatients undergoing oral surgical procedures under general anaesthesia in the dental surgery. Aust Dent J 36:102-108, 1991.

The morbidity in outpatients undergoing oral surgical procedures was examined in this study. Sixty-three percent had a sore throat in the evening after discharge, 28% had a headache, 19% were nauseated, and 12% had dizziness. A sore throat, headache, and dizziness persisted 24 hours postoperatively.

Liu, S.S. Optimizing spinal anesthesia for ambulatory surgery. Reg Anesthesia 1997 Nov-Dec.

Philip BK: Patients' assessment of ambulatory anesthesia and surgery. J Clin Anesth 4:355-8, 1992.

A return-mail questionnaire was given to 3,722 ambulatory patients. Eighty-six percent of respondents reported at least one minor sequela persisting after discharge. Laparoscopy patients experienced significantly more aches, drowsiness, dizziness, sore throat, nausea, and vomiting. Of all patients, 38% were able to return to their usual activities the day after surgery; the remainder required 3 additional days because of general malaise or surgical discomfort.

Power KJ: Anaesthesia for day-case oral surgery. Br J Oral Maxillofac Surg 27:387-393, 1989.

Sixty patients who had wisdom teeth extracted in an ambulatory procedure were studied. Five patients had severe muscle pain that could be reasonably attributed to succinylcholine, despite precurarization with gallamine. Also, despite the use of propofol, 43% of the patients had nausea and 13% vomited. Fentanyl may have contributed to these results.

Saunders PR, Harris MN: Opisthotonus and other unusual neurological sequelae after outpatient anaesthesia. Anaesthesia 45:552-557, 1990.

Neurologic sequelae developed in four patients after outpatient anesthesia in which propofol was used. The authors suggest that perhaps propofol should be avoided in anxious or epileptic patients. Further study is needed.

Zahl K, Apfelbaum JL: Muscle pain occurs after outpatient laparoscopy despite the substitution of vecuronium for succinylcholine. Anesthesiology 70:408-411,1989.

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A. Defining and evaluating the discharge process ( PACU Bypass/Fast-Track Criteria) - TOP

D. Postoperative follow-up - TOP