Transcript OUTPATIENT SURGERY

OUTPATIENT SURGERY
Dr Masood Entezari Asl
OUTPATIENT SURGERY
outpatient (ambulatory, day-case, same-day, come-andgo) surgery and anesthesia continue to evolve in scope
and complexity throughout the world.
 Multimodal regimens for the management of
postoperative pain, nausea, and vomiting promote more
timely discharge, a better quality of recovery, and
greater patient satisfaction.

OUTPATIENT SURGERY
The elements of care that provide for safe and
uncomplicated anesthesia in the outpatient venue are no
less important when the patient is to be discharged after
an overnight hospital stay.
 Sites for outpatient surgery include main operating room
complex or separate operating rooms within a hospital, a
separate facility physically attached to a hospital or on
hospital grounds, or a hospital-independent facility
(freestanding "surgicenter.")

OUTPATIENT SURGERY
Such procedures commonly involve children and include :
 radiation therapy
 interventional radiologic procedures
 neuroradiologic interventions
 compute tomography(CT)/magnetic resonance
imaging(MRI)
 endoscopy
 examination under anesthesia
 auditory evoked potentials
 electroretinography
 bone marrow biopsy
 intrathecal drug therapy

ADVANTAGES OF OUTPATIENT
SURGERY
1.
2.
3.
4.
Decreased medical costs
Increased availability of beds for patients who
require hospitalization
Protection of immunocompromised patients
from hospital-acquired infections
Avoidance of disruption of the family unit by
hospitalization.
Cost savings may extend beyond actual medical
expenses in as much as patients can often return to daily
activity or work sooner.
 An alternative to the same-day surgical concept is a
planned overnight admission to the hospital after
surgery.

OFFICE-BASED ANESTHESIA
Patient preference, convenience, and privacy,
along with theoretically reduced expenses, are
the public's push behind this trend.
 Surgeons enjoy convenience and control over a
lower overhead.
 reduce their costs.
 Today, virtually every medical and surgical
discipline has its office-based procedures.
 The escalating scope and complexity of officebased procedures make provision of monitored
anesthesia care (MAC), regional anesthesia, or
general anesthesia an increasingly common
requirement.

PATIENT SAFETY CONSIDERATIONS




The public deserves and expects a single safety and quality
standard of anesthetic and surgical care regardless of venue
When outpatient surgery is performed in a freestanding
facility or the physician's office, a transfer and admission
agreement with a nearby affiliated hospital must be in place
should unexpected hospitalization be required in the
immediate perioperative period.
The need to deliver a safe anesthetic with minimal
undesirable side effects and rapid recovery is critically
important
for
office-based
surgery.
Short-acting,
fast emergence (SAFE) anesthetics such as propofol,
remifentanil,desflurane, and sevoflurane facilitate timely
achievement of discharge criteria.
Regional anesthesia with longer-acting local anesthetics can
provide excellent analgesia during surgery and effective
postoperative pain relief for complex surgical procedures.
FACILITIES






operating rooms, anesthetic equipment, and recovery facilities
used for outpatient surgery not differ in quality from those
used for inpatient surgery.
Policies and procedures should be consistent
staff should possess equivalent skills and be equally
competent.
staff must be capable of permitting patients to remain for
several hours after surgery if needed.
Having a medical director, often an anesthesiologist, who is
responsible for the medical care delivered in the facility.
Administrative responsibility may be the medical director's or
be under the purview of an individual with administrative
expertise.
PATIENT SELECTION




Selection of individuals for outpatient surgery was determined
by :
1- the characteristics of the patient
2- the type of operation
other elements :
- the psychosocial aspects of the patient
- human and physical resources for preoperative and
postoperative care
- proximity to emergency care
- resources of the facility
- the skill set of both the surgeon and the anesthesiologist
CHARACTERISTICS OF THE PATIENT
Many patients are in good general health
 Having systemic diseases (non-insulin dependent
diabetes mellitus, essential hypertension, seizure
disorder, asthma) that are controlled
 As outpatient surgery continues to expand in
scope, more patients will have severe conditions
 The development and application of less invasive
surgical techniques and better anesthetic
regimens have promoted the performance of more
complex procedures in those more infirm.

CHARACTERISTICS OF THE PATIENT
The venue the night after surgery will have proximity to
emergency care
 Patient or caretaker competence and proximity to
emergency care may permit discharge

PEDIATRIC PATIENTS
Age is not a factor in the selection of patients
 Many operations and diagnostic/therapeutic
procedures in children are amenable to being
performed on an outpatient basis

POSTOPERATIVE APNEA
The age at which premature or full-term infants
can safely undergo surgery and return home
remains controversial
 the subsequent incidence of apnea after inguinal
herniorrhaphy was not less than 5% until post
conceptual age was 48 weeks and gestational age
was 35 weeks.
 Any infant with apnea in the PACU or anemia,
regardless of age, should be admitted to the
hospital

ELDERLY PATIENTS

More important than advanced age is the medical
control of diseases often associated with aging, as
well as provision for social and physical support
of the elderly patient both before and after
surgery and anesthesia.
TYPES OF PROCEDURES








Procedural factors may predict prolonged PACU stay or
unplanned admission to the hospital
Such factors include intraoperative blood loss and duration of the
procedure.
Patient or caregiver (parent/guardian) sophistication and
competence may facilitate discharge in one case and prevent it in
another.
Postoperative complications that might require intensive
physician or nursing management should be very rare.
Pain should be Manageable
Postoperative nausea and vomiting (PONV) should be minimal to
absent.
Operations that require major intervention into the cranium and
thorax remain unacceptable for outpatient surgery
Infected patients and emergency surgery are "disruptive“ and not
usually welcome in an outpatient facility.
PREOPERATIVE PREPARATION AND
INSTRUCTIONS TO THE PATIENT




Coexisting medical conditions must be evaluated to determine
whether the patient's health is acceptable, in need of further
evaluation, or in need of intervention.
Preoperative teaching
Psychosocial issues can be even more important than medical
issues
Examples :
- third-party authorization for the procedure
- transportation to and from the facility
- local lodgings before and after surgery
- access to a telephone
- the ability to understand and follow instructions
- the availability of translation services
- proximity to emergency care
- the competence of the patient's supportive network
TIMING OF PREOPERATIVE EVALUATION
Sick patients or those with psychosocial issues
are best identified early in the process (days
before)
 Some systems rely on the surgeon to identify
such patients
 Others ask that at least the patient's history be
made available beforehand so that the
anesthesiologist can make a determination.

HISTORICAL INFORMATION
Historical information is often obtained through an
oral, written, or electronic questionnaire
 The
questionnaire can be self-administered or
administered by trained staff, a registered nurse, a
nurse practitioner, a nurse anesthetist or an
anesthesiologist
 Security of confidential information is one of the major
concerns.
 Medical conditions may require active intervention
and management or just awareness.
 Examples
commonly include poorly controlled
systemic hypertension, diabetes, anticoagulation, and
chronic pain

MEDICATIONS





Most medications should be continued
Adjustment for Insulin, oral hyperglycemic agents, diuretics,
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and
some psychiatric medications
Taking an oral drug with a sip of water
Patients who require food along with their medication
present an issue that must be dealt with on an individual
basis.
Preoperative interventions now common to inpatient care:
- perioperative βblockade for ischemia
- medications or compression devices
for
thrombosis
- aggressive glucose control
ORIENTATION TO THE FACILITY
Providing information through a tour, video, or web-based
material.
 If parents are allowed to be present for induction of
anesthesia, they should be educated so that they have
realistic expectations of the experience.

LABORATORY DATA REQUIRED
PREOPERATIVELY
depend on : the patient's age, medical history,
physical examination, current drug therapy.
 Routine laboratory tests in the absence of
positive findings on the history or physical
examination are not usually warranted.

PATIENT INSTRUCTIONS
Instructions should be provided in writing or at
least by telephone in the relevant language
 It is best to contact the patient or caretaker
 Arriving 1 to 2 hours before the expected time of
surgery
 Patient with a higher cancellation rate (children
and the mentally challenged) may also be asked
to arrive earlier.

Information Often Provided on the Written Instruction Sheet Given to
Patients When Outpatient Surgery is Scheduled
Verify that the requested laboratory tests are completed
Fasting for solids for 6 hours or longer
Clear fluids are permissible up to 2 hours before induction of anesthesia as approved
by the anesthesiologist
What medications to take (or not take)
Bring inhalers and sleep apnea devices
Wear minimal to no cosmetics or jewelry
Where and when to report for surgery and estimate of discharge time
Must be accompanied by a responsible adult to provide transportation home
Notify the surgeon if there is a change in the patient's medical condition before
surgery
After surgery, resume eating when hungry, starting with clear liquids and
progressing to soups and then a regular diet
Do not drive an automobile (or other mechanized equipment), make important
decisions, or ingest alcohol or depressant drugs for 24 to 48 hours
Telephone number to contact a nurse or physician regarding postoperative
complications
FASTING
Clear fluids (water, black coffee , clear tea, pulp-free
juice, carbonated beverage) in reasonable volumes up to
2 hours before induction of anesthesia.
 Breast milk up to 4 hours before induction
 Infant formula up to 6 hours
 light meal (dry toast, milk) up to 6 hours before
induction
 Consideration for conditions (gastroparesis) that slow
the transport of food through the gastrointestinal tract
 In practice, misunderstanding or failure to follow fasting
instructions is a very common reason for cancellation or
postponement of surgery

ARRIVAL ON THE DAY OF SURGEYR
Compliance with preoperative instructions is verified
particularly with respect to the ingestion of solid food and
clear liquids
 Preoperative database including the patient's health
history and physical examination, indicated laboratory or
study results, and surgical consent must be rechecked for
completeness

CHECK-IN PROCEDURE
State requirements for timeliness of the history
and physical examination vary :
- within 7 days of the procedure.
- At the time of surgery
- within 24 hours of surgery
 A check-in procedure confirms :
- the identification of the patient
- the nature of the procedure
- the surgical site
 Patients change into a gown if indicated, NPO
times are confirmed, vital signs are obtained, and
if indicated, an intravenous catheter is inserted.

ROLE OF THE ANESTHESIOLOGIST
reviewing the patient's medical record, laboratory data,
and surgical consent and verifying the site of surgery
 Vital signs are noted and current medications and
medication allergies reviewed
 pediatric patients must be thoroughly evaluated for the
recent onset of an upper respiratory tract infection

PEDIATRIC PATIENTS AND
RHINORRHEA
Benign rhinorrhea is usually an allergic rhinitis that
does not contraindicate elective surgery
 An ill appearance and a body temperature higher than
38°C are suggestive of an infectious rather than a
noninfectious process

PREOPERATIVE MEDICATION
preoperative medication for ameliorating anxiety and
addressing preoperative discomfort
 Additional medication acutely to treat systemic
hypertension,
institute
β-blockade
,
treat
bronchoconstriction,
prevent
infection
(prophylactic antibiotics), control blood glucose
concentrations, and provide corticosteroid coverage.
 Drugs administered for preoperative medication should
neither delay recovery from anesthesia nor produce
excessive amnesia.
 Fentanyl (1.0 чg/kg IV) and midazolam (0.04 mg/kg IV)
administered before induction of anesthesia tend to
decrease
anesthetic
requirements and
airway
irritability and do not delay recovery.

PEDIATRIC PATIENTS
The need for pharmacologic premedication may
be less if the parents are calm and can
participate in the induction of general anesthesia
or physical transfer of the child to the nurse or
anesthesiologist
 Preoperative administration of midazolam (0.5 to
1.0 mg/kg orally or rectally) is effective in
promoting separation from the parents within 20
to 30 minutes and is not associated with delayed
recovery

MENTALLY CHALLENGED PATIENT
Uncooperative, mentally challenged adults pose
unique issues because they cannot be physically
manipulated as easily as children
 Some will cooperate and accept insertion of an
intravenous catheter
 Others may cooperate with inhalation induction
of anesthesia
 Regimens include midazolam, up to 20 mg orally,
ketamine, 2 to 3 mg/kg intramuscularly, or a
combination of midazolam (0.3 mg/kg) and
ketamine (2 mg/kg) intramuscularly

GOALS
Preoperative medication intended to decrease
preoperative anxiety in adults is most often provided by
the administration of small doses of midazolam (1 to 2 mg
IV)
 Sedation can be produced by the oral administration of a
benzodiazepine such as diazepam
 Unmedicated patients may walk to the operating room,
whereas others may be transported by gurney or
wheelchair.

PROPHYLAXIS AGAINST POSTOPERATIVE
NAUSEA AND VOMITING



A
prophylactic
antiemetic
(serotonin
antagonists,
corticosteroid) may be useful for patients who :
(1) have a history of PONV
(2) are subject to motion sickness
(3)
are
undergoing
operations associated
with
a high incidence of PONV.
The routine use of prophylactic antiemetics remains
controversial because a large percentage of patients do not
experience nausea and vomiting
As with inpatients, outpatients considered to be at risk for
pulmonary
aspiration
may
receive
preoperative
pharmacologic therapy intended to speed gastric emptying,
increase gastric fluid pH, or decrease gastric fluid volume.
Any antacid administered orally should be clear,
not particulate.
USE OF ANTICHOLINERGICS

an antisialagogue effect may be useful before
procedures involving the oropharynx, where
excessive secretions could interfere with the
production of topical anesthesia.
TECHNIQUES OF ANESTHESIA







All techniques of anesthesia (general anesthesia, regional
anesthesia, local anesthesia with or without sedation, and
MAC) and most drugs available to inpatients are also
appropriate for outpatients.
Prompt and nearly complete recovery with minimal side
effects (residual sedation, PONV; orthostatic hypotension,
pain) is ideal
Expense may be a factor in the choice of anesthetics
The cost of sedation is usually less than the cost of a
general anesthetic.
The incidence of PONV tends to be less after local
anesthesia and MAC than after general anesthesia
Awakening is usually more rapid after local anesthesia and
MAC than after general anesthesia
The safety of modern ambulatory anesthesia is impressive,
and the complications that occur in these patients are
generally easily managed and self-limited
GENERAL ANESTHESIA








General anesthesia is frequently selected for outpatient surgery.
Its onset is fast and it can be controlled easily
Administration of so-called SAFE drugs for general anesthesia
Propofol has become the induction drug of choice for patients
undergoing outpatient surgery despite the availability of
alternative drugs (thiopental, etomidate).
Psychomotor recovery is more rapid after induction of anesthesia
with propofol
have less nausea and vomiting
patients may experience euphoria on emergence from propofol
anesthesia, especially when combined with the ultrashort-acting
opioid remifentanil
Etomidate is associated with rapid awakening, but the increased
incidence of myoclonic movements and PONV detracts from its
use for outpatients.
INDUCTION OF ANESTHESIA IN
PEDIATRIC PATIENTS






Facilitating cooperation for inhalation induction of anesthesia by :
- Introduction to the facemask
- choice of "flavored medicine“
- parental presence
- involvement of the child in a game or story
- premedication
With skill, a small-gauge intravenous catheter can be placed with
minimal discomfort
When inhalation induction of anesthesia is planned, the most
frequently selected drug is Sevoflurane
Sevoflurane does not cause airway irritation
Poor solubility in blood permits more rapid achievement of an
anesthetizing concentration than is possible with halothane
Postoperative delirium in children may result from the rapid
offset of drugs such as sevoflurane.
AIRWAY ADJUVANTS






Facemasks and oral airways may be used during
anesthesia for brief and superficial surgical
procedures
The laryngeal mask airway (LMA) and other
supraglottic airway devices have completely changed
airway management for such patients
In comparison with tracheal intubation, use of an
LMA does not require neuromuscular blocking drugs
nor their antagonism
An LMA tends to be less irritating, and placement is
associated with a smaller hemodynamic response and
a smaller rise in intraocular pressure
The original LMA Classic does not protect the airway
from aspiration, and the use of positive-pressure
ventilation may be questionable
The LMA ProSeal attempts to address both issues.
TRACHEAL INTUBATION
Some patients and procedures require tracheal
intubation
 A disadvantage of succinylcholine in outpatients is the
occasional occurrence of myalgia.
 Spontaneous recovery from the effects of mivacurium
is prompt
 Atracurium,
cisatracurium,
vecuronium,
and
rocuronium are somewhat longer-acting alternatives
 Some believe that any nondepolarizing neuromuscular
blockade should be antagonized
 Others feel comfortable if the blockade has fully
resolved spontaneously as reflected by neuromuscular
blockade monitoring or clinical criteria.

MAINTENANCE OF ANESTHESIA





Maintenance of anesthesia is often achieved with the
combination of nitrous oxide and a volatile anesthetic
(desflurane or sevoflurane)
Nitrous oxide may be avoided based on the concern that
this gas promotes PONV
An alternative to volatile anesthetics for maintenance of
anesthesia is the continuous intravenous infusion of
propofol, usually with an adjunct such as fentanyl,
remifentanil, or ketamine.
Total intravenous anesthesia (TIVA) techniques avoid all
inhaled anesthetics and may include a neuromuscular
blocking drug
Inhaled and intravenous anesthetics are not mutually
exclusive, and many use them in combination.
ANALGESIA






Analgesia is best provided by the use of a local anesthetic
administered by :
- infiltration
- nerve block
- plexus block
- intra-articular
- intracavitary
- topical
Opioids such as fentanyl and meperidine have traditionally been
used to provide perioperative analgesia
Such drugs are associated with side effects, including respiratory
depression, drowsiness, PONV, pruritus, and urinary retention-each
of which can delay discharge and produce dissatisfaction
Analgesic modalities include NSAIDs, acetaminophen, ketamine, and
a2 agonists such as clonidine and dexmedetomidine
Severe postoperative pain in adults may require acute treatment by
the intravenous administration of an opioid such as fentanyl,
meperidine, or hydromorphone.
Severe, protracted pain remains a common reason for unanticipated
hospital admission after planned outpatient surgery
POSTOPERATIVE NAUSEA AND
VOMITING
Treatment of severe postoperative vomiting may
include the rescue administration of ondansetron,
dexamethasone, promethazine, or dimenhydrinate
 For motion-related PONV some find intramuscular
hydroxyzine or ephedrine (or both) efficacious
 Protracted PONV is a common reason for prolonged
time in the PACU or unanticipated hospital admission
after planned outpatient surgery.

REGIONAL ANESTHESIA
Regional anesthetic techniques in outpatient surgery:
- peripheral nerve blocks (femoral, median, sciatic
nerve)
- combination of peripheral nerve blocks (ankle, hand
block)
- brachial or lumbar plexus blocks
- neuraxial blocks (spinal and epidural)
 Performing a regional anesthetic may take longer than
inducing general anesthesia, and the possibility of failure
exists.

TECHNIQUE





Regional anesthesia may be used in combination with
intravenous sedation or general anesthesia
Except in children, the administration of a neuraxial block
is not recommended when the patient is unconscious
An unconscious patient cannot report pain or severe
paresthesia
Adjuncts to improve the success and reduce the
complications associated with regional anesthesia include
the use of an electrical stimulator with an insulated needle
and ultrasound guidance to localize the nerve.
Recovery from the effects of a regional anesthetic (sensory,
motor, and sympathetic nervous system blockade) can take
longer and delay ambulation when compared with recovery
from a general anesthetic
SPINAL ANESTHESIA











Spinal anesthesia does not need to be avoided in outpatients
The use of very thin (>=25-gauge), rounded- or pencil-point
needles reduces the incidence of post-dural puncture headache
(PDPH)
The headaches are usually mild and self limited
Many believe that early ambulation does not increase the
incidence of PDPH
Epidural anesthesia may become a suitable alternative to spinal
anesthesia
Prolonged spinal block can delay discharge and lead to patient
frustration and urinary retention in susceptible males.
Epinephrine should not be added to the local anesthetic solution
lidocaine has been used for spinal anesthesia in the outpatient
setting because of its short duration of action
Concern about painful transient radicular symptoms after spinal
anesthesia with lidocaine has reduced its popularity substantially
Procaine,
mepivacaine,
bupivacaine,
ropivacaine,
and
levobupivacaine may provide alternatives to lidocaine
Concomitant administration of intrathecal fentanyl can also be
useful
POSTOPERATIVE ANALGESIA
Postoperative use of patient-controlled analgesia
or epidural local anesthetic/opioid infusions has
not proved practical for analgesia after
outpatient surgery
 Indwelling peripheral nerve and plexus catheters
that allow continuous instillation of low doses of
local anesthetic solution may be used for
postoperative analgesia after more complex
procedures involving the extremities
 Such techniques give the patient a reusable or
disposable reservoir and pump to use at home
 Patient and caretaker education about its proper
use and potential complications is mandatory

SEDATION AND ANALGESIA





Anesthesia for many outpatient surgical procedures, invasive
medical procedures, and diagnostic tests can be accomplished
simply and effectively by the use of intravenous sedative-hypnotics
and analgesics
MAC entails the administration of these drugs and monitoring of
the patient's vital signs by an anesthesiologist
The combination of a regional anesthetic or local infiltration
anesthesia with the intravenous injection of drugs to produce
sedation or analgesia (or both) is particularly well suited for
outpatient surgery.
Drugs commonly administered to adults to produce sedation and
amnesia include midazolam or propofol
Continuous low-dose intravenous infusion of propofol (25 to 100
чg/kg/min) is particularly useful for producing sedation more
painful procedures or when a peripheral nerve block requires
supplementation, an opioid such as fentanyl (25 to 50 чg IV) or an
infusion of remifentanil (0.075 to 0.15 чg/kg/min) or ketamine (5 to
20 чg/kg/min) may be useful
DISCHARGE FROM THE OUTPATIENT
FACILITY





Discharge from the outpatient PACU is based on specific
criteria and documentation that the residual effects of
anesthesia have dissipated
More important is the use of criterion-based milestones to
determine the propriety of discharge
Hospital-based outpatient facilities may admit
postoperative outpatients to a PACU more suited for
inpatient care (first stage or phase I)
When defined criteria are met, patients then transfer to a
less intensive and acute care area where they may still
recover on a gurney or flattened recliner (second stage or
phase II)
Patients who meet these criteria in the operating room or
very soon after leaving the operating room may be admitted
directly to this phase II area (Table 36-2)
TABLE 36-2 FAST-TRACK CRITERIA FOR DIRECT TRANSFER FROM
THE OPERATING ROOM TO THE PHASE II UNIT AFTER GENERAL
ANESTHESIA
Score
level of Consciousness
Aware and oriented
2
Arousable with minimal stimulation
1
Responsive only to tactile stimulation
0
Physical Activity
Able to move all extremities on command
2
Some weakness in movement of extremities
1
Unable to voluntarily move extremities
0
Hemodynamic Stability
Systemic blood pressure <15% of baseline MAP value
2
Systemic blood pressure 15% to 30% of baseline MAP value
1
Systemic blood pressure >30% below baseline MAP value
0
Respiratory Stability
Able to breathe deeply
2
Tachypnea with good cough
Dyspnea with cough
1
0
Oxygen Saturation Status
Maintains value >90% on room air
2
Requires supplemental oxygen (nasal prongs)
1
Saturation <90% with supplemental oxygen
0
Postoperative Pain Assessment
No or mild discomfort
2
Moderate to severe pain controlled with IV analgesics
1
Persistent severe pain
0
Postoperative Emetic Symptoms
No or mild nausea with no active vomiting
2
Transient vomiting or retching
1
Persistent moderate to severe nausea and vomiting
0
TOTAL SCORE
14
CONTINUE





A minimal score of 12 (with no score less than 1 in
any individual category) is required for a patient to
bypass the postanesthesia care unit ("fast-tracked")
after general anesthesia.
Admitting a postoperative patient directly to a less
acute PACU environment from the operating room is
called "fast tracking”
Slightly different criteria apply for determining
"home readiness" (Table 36-3)
Eating or drinking successfully is seldom a criterion
for discharge unless the patient has diabetes mellitus,
has a long trip home, or is at risk for dehydration
Forcing food often leads to PONV
TABLE 36-3 CRITERIA FOR DETERMINATION OF A DISCHARGE SCORE FOR
RELEASE HOME TO A RESPONSIBLE ADULT
Variable Evaluated
Score
Vital signs (stable and consistent with age and
preanesthetic baseline)
Systemic blood pressure and heart rate within 20% of
preanesthetic level
2
Systemic blood pressure and heart rate within 20% to 40% of
preanesthetic level
1
Systemic blood pressure and heart rate >40% of preanesthetic
level
0
Activity level
Steady gait without dizziness or meets preanesthetic level
2
Requires assistance
1
Unable to ambulate
0
Nausea and vomiting
None to minimal
2
Moderate
1
Severe (continues for repeated treatment)
0
Variable Evaluated
Score
Pain (minimal to no pain, controllable with oral
analgesics)
Yes
2
No
1
Surgical bleeding (consistent with that expected for the
surgical procedure)
Minimal (does not require dressing change)
2
Moderate (up to two dressing changes required)
1
Severe (more than two dressing changes required)
0
PATIENTS ACHIEVING A SCORE OF AT LEAST 9 ARE
ACCEPTABLE FOR DISCHARGE
POSTOPERATIVE INSTRUCTIONS
Before discharge reviewing
the postoperative
instructions for wound care, medications, and return to
activities and telephone contact information for
questions and emergencies
 Distinguishing expected postoperative symptoms from
more important complications
 Most facilities ask that surgeons give patients
prescriptions for postoperative medications before the
time of surgery so that such medications can be
obtained before the trip home
 Giving a "starter pack" containing enough oral
analgesics for the first night

COMMON POSTOPERATIVE PROBLEMS
most common reasons for protracted stay in the
PACU :
- PONV
- pain
- drowsiness
 Urinary retention in those at risk may also delay
discharge
 The unanticipated postoperative admission rate
to the hospital is less than 1%.

PATIENT EXPECTATIONS







A patient's expectations of the postoperative period should be
realistic
reassuring the patients that efforts to control pain and PONV will
not stop after discharge
Mental clarity and dexterity may remain impaired for as long as
24 to 48 hours despite an overall feeling of well-being
Important decisions, driving an automobile, or operation of
complex equipment should not be attempted during this period
Discouraging the ingestion of alcohol or depressant drugs because
of additive responses with residual anesthetic effects
The diet should initially consist of clear liquids and progress to
easily digested food (soups, cereal) and then a regular diet as
tolerated.
Complications need to be addressed immediately and
dissatisfaction addressed in a timely and appropriate manner