Postoperative management of outpatient anaesthesia

 

(Version 2.2.2000)

 

 

 

Kari Korttila MD,PhD

 

Abstract for 3rd EuroSIVA Meeting on Intravenous Anaesthesia

Vienna, March 31-April 1, 2000

 

Address:

Kari Korttila. MD.Ph.D.

Professor of Anaesthesia and Crit Care

University of Helsinki

Women’s Hospital

P.O.Box 140 (Haartmaninkatu 2)

FIN-00029 HYKS, FINLAND

 

E-mail: kari.korttila@hus.fi

Fax: +358-9-47174803

 

 

 

 

 

 

 

Postoperative management of outpatient anaesthesia

Kari Korttila, MD, Ph.D.

University of Helsinki

kari.korttila@hus.fi

 

In outpatient surgery the patient arrives and leaves the surgery unit during the same day. Patients are usually discharged within a couple of hours, sometimes as early as within 30 minutes and almost always within 12 hours of surgery. Since day surgery has been reported to both create savings in health care costs and have a remarkable record of safety, its popularity continues to increase worldwide. An ideal anaesthetic used for day surgery should provide a pleasant anaesthesia with fast recovery and as little residual effects as possibly. This presentation will discuss postoperative patient care.

 

Inpatient or outpatient surgery? In the past only healthy patients undergoing small procedures were eligible for day surgery. Today, elderly patients with systemic diseases (stable ASA III or IV class) undergoing surgery for, e.g. a 3-4 hours for breast surgery, can be offered the benefits of day surgery. Reasons which would prevent safe discharge of a surgical patient on the day of operation are uncontrollable pain or postoperative nausea and vomiting (PONV), major problems with cardiovascular, pulmonary or hepatic system.

 

Recovery and Discharge. The safety and success of day surgery depends on appropriate and timely discharge of patients and little discomfort after surgery. Premature discharge may cause problems on the way home or at home but prolonged recovery with “too late” discharge may back up recovery rooms and increases nursing needs. Guidelines for safe discharge after day surgery  include ability to walk unassisted and good control of pain and  postoperative nausea and vomiting. The role of different scoring systems to assess home-readiness after outpatient anaesthesia needs further investigations. It is obvious that there should be no bleeding or oozing from the wound and that a responsible adult is needed for transport and at home. It is not necessary that all patients should be required to drink and void before discharge. Voiding should be compulsory after spinal and epidural anaesthesia and after cystoscopy and it is highly recommended after inguinal hernia repair and other surgery in the pelvic area.  In regard to upper extremity or shoulder surgery patients are generally discharged home when the regional block (axillary or interscalene) has not worn off. This stresses the importance of proper prevention and treatment of pain at the time and after the block wears off at home.

 

Postoperative pain and emesis . Prevention of both postoperative pain and PONV is one of the “keys to success” with day surgery. NSAID’s alone or together with fentanyl are commonly used for this purpose in day surgery. Regional anaesthetic techniques are likely to be associated with less nausea and vomiting than general anaesthesia. However, e.g. hypotension during spinal anaesthesia and the adjuvant drugs given together with regional anaesthesia may contribute to PONV. For both pain and PONV combination therapies (balanced or multimodal techniques) gives the best results.

Patients who received balanced pain prevention for laparoscopic tubal ligation (combination of lidocaine gel to clips and fentanyl plus ketoprefen i.v.) had much less pain, became home-ready much faster and returned to normal daily activities 1-2 days earlier when compared to patients who did not receive this combined therapy(1). Similarly patients undergoing outpatient laparoscopic cholecystectomy  had no or only mild pain after operation if multimodal pain prevention ( 75-100 mg 0.5% bupivacaine with adrenaline intra-abdominally plus pethidine i.m. and ketorolac) had been applied during surgery(2).  Patients who did not receive such a combined therapy had more pain which was often discomforting and lasted long.

Wound infiltration has traditionally been one way of preventing postoperative pain. Rawal(3) has used patient controlled regional anaesthesia to control pain after hand surgery using a subcutaneous needle on both sides on the wound. In the future longer acting local anaesthetics may offer some advantages to postoperative pain relief in day surgery.

A combination therapy is recommended for prevention and treatment of PONV. A combination of a small dose of droperidol (0.01 mg/kg i.v.) and a  5-HT3 - receptor antagonist ( e.g. ondansetron 4 mg or dolasetron 12.5 mg i.v.) given at the end of surgery should give a good protection for patients with intractable PONV after prior anaesthetics. It remains to be seen, if the combination of propofol anaesthesia and PONV  prophylaxis with dexamethasone (4 mg IV), droperidol (0.01 mg/kg IV) and a  5-HT3 - receptor antagonist (e.g. ondansetron 4 mg IV) would eliminate PONV on most patients.

 

Monitored Anaesthesia Care (MAC). With MAC a regional technique can be made more acceptable and comfortable to the patients and may allow fast discharge after surgery.  Regional anaesthesia with MAC suits extremely well for patients undergoing cataract and other eye surgery, dental surgery, breast surgery, arthroscopic surgery and to small orthopaedic surgery. The most commonly used technique for MAC is to use small doses of midazolam (1-2 mg) i.v. and fentanyl (0.05mg) i.v. combined with a low dose propofol infusion (1.5-3 mg/kg/h). Recovery after such technique is extremely rapid. In United States many patients will by-pass phase I recovery room (“fast tracking”) after MAC and will go home very early after the surgery. MAC has been discussed in more detail in two recently published review articles(4,5).

 

Cognitive function after discharge. It is obvious that when patients meet different criteria for home-readiness indicating that they can safely go home after day surgery many of them are not fully recovered. It is usual and customary to recommend patients to refrain from driving and operating machinery for at least 24 hours after anaesthesia although there is no hard scientific data on this matter. Studies funded by European Community are being carried out to find out if and for how long postoperative cognitive dysfunction will last after outpatient anaesthesia and surgery .

 

References

 

 1.        Eriksson H, Tenhunen A, Korttila K: Balanced analgesia improves recovery and            outcome after outpatient tubal ligation. Acta Anaesthesiol Scand 1996;40:151-55.

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

3.         Rawal N, Axelsson K, Hylander J et al: Postoperative patient-controlled local anesthetic administration at home. Anesth Analg 1998;86:86-9

4.         Sá Rêgo MM, White PF: Monitored anesthesia care: an alternative to general and regional anesthesia. Curr Opin Anaesthesiol 1997; 10:430-37.

5.         Smith I, Taylor E: Monitored anesthesia care. Int Anesthesiol Clin 1994; 32: 99-112.