庆祝上市 全新改版

Re:【原创】知识更新-门诊手术的麻醉 AMBULATORY SURGERY

28.How is pain best controlled in the ambulatory patient in the PACU?
Management of postoperative pain in the PACU as well as after discharge is of major concern to the anesthesiologist. Adequate pain relief must be achieved before a patient may be discharged and patient comfort in the postoperative period is important. The prevention of postoperative pain appears much easier to accomplish than the treatment of pain that has been allowed to reach significant intensity. Unfortunately, the occasional inability to manage postoperative pain remains a cause of unexpected overnight hospitalization.
In procedures for which patients can be anticipated to experience significant postoperative discomfort, the addition of an opioid as part of the anesthetic is helpful. A propofol anesthetic will not provide postoperative analgesia. The intraoperative administration of long-acting local anesthetics such as bupivacaine, 0.25–0.5%, at the surgical site may provide hours of postoperative pain relief. This technique has proven to be most efficacious following inguinal and umbilical hernia repairs and minor breast surgery. The efficacy of intra-articular local anesthetics and opioids following arthroscopy of the knee joint has been shown to be of value. Other techniques such as performance of a penile block or the topical application of lidocaine jelly on the penis following circumcision have proven effective in reducing discomfort. The use of ilioinguinal and iliohypogastric nerve blocks is efficacious in adults and children following herniorrhaphy. Repeating maxillary or mandibular nerve blocks at the conclusion of oral surgery is efficacious.
In the PACU, careful titration of small intravenous doses of opioids can safely provide satisfactory analgesia. The blood levels of opioids that are required to provide analgesia are less than those that usually result in significant respiratory depression or marked oversedation. Fentanyl is the narcotic of choice in the postoperative period for treating pain. Its duration of action is modest, and intravenous doses of 25–50 mg may be repeated every 5 minutes until satisfactory pain relief has been achieved. Medicating patients with oral opioid preparations before discharge will provide a patient with a more comfortable trip home because the intravenous drugs administered in the PACU have relatively short durations of action.
The home use of patient-controlled analgesia systems permits the discharge of patients who are expected to experience pain that may not be sufficiently controlled with oral agents. Experiments with patient-controlled analgesia in the home have found this modality of pain relief to be both safe and effective. Oxycodone and codeine are suitable for amelioration of mild-to-moderate pain but are not strong enough to prevent hospitalization in a patient who experiences severe pain.
Ketorolac, a nonsteroidal anti-inflammatory agent, has been administered orally, intramuscularly, and intravenously in an attempt to prevent and relieve pain and reduce opioid requirements. The drug itself is free of opioid-related side-effects including sedation and vomiting. Some are hesitant to employ this class of drugs because of their potential for causing bleeding. Further, when administered orally, gastric irritation may be encountered. COX-2 inhibitors minimize the potential for postoperative bleeding and the risk of gastrointestinal complications and thus are becoming popular as a non-opioid adjuvant for treating postoperative pain.
29.What discharge criteria must be met before a patient may leave the ambulatory surgery center?
Most institutions divide postanesthesia care into two phases. The first phase begins when the patient first enters the recovery area. The second phase, or step-down phase, begins after stability of vital signs has been achieved and the major effects of anesthesia have dissipated. At this point, the patient can be comfortably transferred into a recliner chair, either in the same area or in another unit (Table 77.5).
Patients who have received a spinal or epidural anesthetic can only be discharged when full motor, sensory, and sympathetic function has returned. An inpatient who will remain at bed rest might be discharged from the PACU to the nursing unit while minimal residual neural blockade persists; in the case of the ambulatory patient, however, it is essential that the block has completely dissipated.
Following administration of an epidural or spinal anesthetic, the patient should demonstrate the ability to void. This provides evidence that residual sympathetic blockade has dissipated. Of course, before attempting to ambulate a patient, it is essential to ensure that all motor block has resolved.
Patients who have received an ankle block, brachial plexus block, or peripheral nerve block may be discharged despite the persistence of residual anesthesia or paresthesias. The arm or foot should be protected from harm with either a sling in the case of the arm or a bulky dressing in the case of the foot. The patient needs to be reminded that in time the block will dissipate and discomfort will appear. For this reason, instructions should be given to take the prescribed oral analgesic medication at the first sign of discomfort, because pain is most readily treated before it becomes excruciating.
Patients who have received general anesthesia may awaken either in the operating room or shortly after transfer to the PACU. Although the patient may appear to be lucid and oriented, numerous criteria must be satisfied before a patient may be considered to be ready for discharge from the facility. A restoration of vital signs within 15–20% of the preoperative baseline is ordinarily required. Patients should demonstrate an intact gag reflex and the ability to cough effectively and swallow liquids without difficulty. It is not necessary for patients to eat before discharge. Forcing patients to ingest unwanted food in the absence of hunger may simply serve to increase the incidence of postoperative nausea and vomiting. Ordinarily, the patient is asked to demonstrate the ability to tolerate a small amount of liquid. If a patient experiences mild nausea and has not been able to ingest more than a few sips without precipitating vomiting or increased nausea, it is foolish to persist. Discharge can still be considered, but written instructions must be provided regarding steps to be taken (contact facility or surgeon) if there is continued inability to tolerate fluids. It is important to ensure that a normal state of hydration has been achieved before discharge. This is especially important following surgery in the oral cavity, where postoperative pain may preclude early oral intake.
Unless the patient was previously unable to walk or the procedure performed precludes ambulation, patients should be able to walk with assistance and without experiencing dizziness. If crutches are required, it should not be assumed that the patient received preoperative instruction. Additional instruction should be offered. Hemostasis should be present at the surgical site, and control of pain should be satisfactory. The preoperative level of orientation should be achieved, although a mild degree of residual sedation is acceptable.
It is not essential for a patient to demonstrate the ability to urinate unless genitourinary, gynecologic, or other surgery has been performed in the inguinal or perineal region. The patient and the escort should be instructed of the need to contact either the ambulatory facility or the surgeon if the patient has not voided within 6 hours following discharge from the recovery area.
Postanesthesia discharge scoring systems have been proposed and developed for the purpose of assessing when home readiness is achieved in the postoperative period. Criteria such as mental status, pain intensity, ability to ambulate, and stability of vital signs are given numeric values. A total score above a particular number may indicate a high likelihood of readiness for discharge. To be practical, a scoring system must be readily understood, simple to employ, and objective. Sophisticated pen-and-paper and neuropsychological tests to assess recovery from anesthesia are reserved solely for research purposes. Actually, after stability in vital signs is achieved, the ability of a patient to walk and urinate may be the best measure of a patient’s gross recovery from an anesthetic and signal readiness for discharge. These activities indicate return of motor strength, central nervous system functioning, and restoration of sympathetic tone.
Each patient and escort should receive a set of detailed, written discharge instructions regarding activity, medications, care of dressings, and bathing restrictions. Instructions must be reviewed verbally with the patient and escort, and they must be signed by the patient or escort, if the patient is incapable. Both must be aware of the need to contact the facility in the event of untoward reactions or any difficulties that may arise such as bleeding, headache, severe pain, or unrelenting nausea or vomiting. The majority of postoperative complications occur after the patient has been discharged. Therefore, it is important to ensure comprehension of all information by the patient or designated escort (Table 77.6).
Most states have a mandatory requirement that patients who have received other than a local anesthetic be discharged in the company of a responsible adult. Current definitions of “responsible adult” vary and may be broadened to include emancipated minors or responsible older children. Theoretically, the companion should be willing and able to remain with the patient for at least the first 24 hours after surgery. This is especially important when dealing with the geriatric or debilitated patient. Problems may arise when an octogenarian patient is discharged in the company of an octogenarian spouse. Ideally, two adults should accompany pediatric patients from recovery room to home. After discharge, a child may suddenly experience nausea or vomiting, pain, fright, or disorientation. A parent who is driving a car cannot possibly attend to both responsibilities simultaneously.
A clear distinction is made between “home readiness” and “street fitness.” Home readiness signals that the time has arrived to discharge the patient from the recovery area. On the other hand, “street fitness” is attained after approximately 24 hours have elapsed, when most of the more subtle and persistent central nervous system effects of general anesthesia have dissipated. Patients must be advised not to resume normal activities immediately upon returning home.
Formal discharge criteria must be in place, and final evaluations should be conducted immediately before a patient’s discharge from the unit. All perturbations from normal, including vital signs and unusual symptoms, must be addressed.
Every attempt must be made to avoid premature discharge of the patient from the PACU. The consequences of such faulty judgments may include the necessity for emergency care elsewhere and possible readmission to another health care facility. When any element of doubt exists as to the stability or suitability of a patient for discharge, the better part of valor is to arrange for hospital admission for overnight observation.
30.What are the causes of unexpected hospitalization following ambulatory surgery?
Although a patient may be scheduled to return home after surgery, admission may be required for a host of reasons. Approximately one quarter of the unexpected admissions following surgery are anesthesia-related. The remainder result from either medical or surgical complicating factors (Table 77.7)
Most ambulatory surgical facilities experience an unexpected hospital admission rate that ranges from less than 1% to approximately 4%. Unexpected hospitalization is greater with general anesthesia compared with local or regional anesthesia. As might be anticipated, the addition of intravenous sedation to a local anesthetic increases the complication rate. Nausea and vomiting, dizziness, bronchospasm, and delayed emergence from anesthesia are common causes of anesthesia-related hospital admission.
31.When may patients operate a motor vehicle after receiving a general anesthetic?
Current recommendations are to advise patients to refrain from operating heavy machinery including driving a car for approximately 24–48 hours after the administration of either a general anesthetic or intravenous sedation. While a patient may appear to himself or herself and to others to be completely recovered, subtle psychomotor disturbances and cognitive deficiencies may persist in the postoperative period. Important decision-making, as well as activities requiring fine motor coordination, should be postponed until after the first postoperative day. Despite admonitions to the contrary, postoperative patient surveys have revealed that some patients drive their automobiles within 24 hours after surgery, and some may even drive home from the facility.
As a result of central nervous system derangements or the surgery itself, patients may experience minor slips or even major falls after discharge. Some of these events may be related to confusion or subtle alterations in mental state. Others may be due to dizziness or pain. It is hoped that anesthetic agents of the future will be free of the prolonged and potentially hazardous central nervous system dysfunction seen with currently available drugs.
32.What is the role of aftercare centers for the ambulatory surgery patient?
Following some surgical procedures, patients may experience significant postoperative pain that cannot be readily controlled with oral opioids. Additionally, although they may require some skilled nursing observation or specialized care, these may be accomplished outside the setting of an acute care hospital both at lower cost and with greater comfort for the patient and family. With this in mind, the concept of a recovery care facility was born, thus creating a new category of inpatient postsurgical care. This healthcare model integrates ambulatory surgery with overnight or extended care outside of a hospital. Examples of procedures included in the present trial include hysterectomy, cholecystectomy via laparotomy, shoulder repairs, and mastectomies. If this type of facility is unavailable, appropriate use of home care services including newer modalities of pain control may still allow a patient to avoid inpatient postoperative care.
33.Are quality assurance and continuous quality improvement possible for ambulatory surgery?
To ensure quality as well as patient satisfaction, follow-up telephone calls by an anesthesiologist should be made to all patients on the first postoperative day. Some facilities make two additional calls, one on the evening of surgery and another 1 week following surgery. Postage-paid postcards may be sent to patients requesting information on the overall experience as well as specific areas of care. Space may be allocated for the patient to note side-effects or adverse occurrences. Depending on surgeons to provide accurate feedback regarding complications is unreliable. Therefore, a mechanism for follow-up must be in place to uncover and identify patterns that may require remedial action.
28. 怎么使门诊手术病人在麻醉后恢复室(PACU)得到最好的镇痛?
PACU病人术后疼痛管理是继出院之后对麻醉医生最重要的事情。离院前必须充分减轻疼痛和病人术后期的舒适是重要的。预防术后疼痛发生较治疗疼痛达到一定的程度要容易的多。不幸的是,偶尔发生难以处理的疼痛,会导致我们不期望发生的病人不得不住院过夜留置观察。对于预测可能发生术后不适病人麻醉时,加入阿片类作为麻醉的一部分是有用的。异丙酚麻醉不能提供术后镇痛。术中手术部位给予0.25-0.5%的长效局麻药可以产生术后几个小时的疼痛减轻。在腹股沟疝和脐疝修补术,小范围乳腺手术效果都非常明显。关节镜检查后,膝关节腔内给局麻药和阿片类药物也是很有效的。其他如对包皮环切病人阴茎神经阻滞,或表面涂抹利多卡因膏剂都有助于减轻不适。髂腹股沟和髂腹下神经阻滞在成人和小儿疝修补病人都是有效的。多次上下颌神经阻滞对口腔手术病人也是有效的。
在PACU病人精确静脉给阿片类药物可以安全的达到满意的镇痛。产生镇痛的血药水平要低于引起显著呼吸抑制或过度镇静的水平。芬太尼是疼痛治疗可以选择的麻醉药。它作用时间中等,静脉25-50mg,每分钟可重复给药直道达到我们期望的减轻程度。给准备离院的病人口服阿片类镇痛药,可以使病人回家途中更舒适,因为在PACU静脉给药作用时间较短。
对认为口服镇痛药不足以有效镇痛的病人来说,家庭用自控镇痛(PCA)装置的使用也可以让病人离开医院。对病人家庭自控镇痛的研究表明它是安全、有效的。羟考酮和可待因适合改善轻中度疼痛,但对因疼痛住院的病人是不够的。
痛力克是一种非甾体类抗炎药,曾被口服,肌注和静脉给药试图预防和减轻疼痛,减少对阿片类药物的需求。它本身没有阿片类相关的恶心、呕吐等副作用。但是医生对使用这类药物很犹豫,因为它有潜在出血的危险。另外,口服时对胃有刺激。COX-2抑制剂可潜在的减少出血,和胃肠并发症的风险,因此常作为非阿片类药物治疗术后疼痛。
29. 病人离开门诊手术中心必需达到的标准是什么?
大部分机构把麻醉后监护分为两期。一期从病人进入复苏区开始。二期从病人生命体征已经稳定,主要麻醉效应已经消失开始。这时,病人可以舒适的坐进躺椅,仍在这个房间或到另一个房间(表 77.5)。
椎管内麻醉的病人只有运动,感觉和交感神经功能功能完全恢复才能离开。在PACU卧床休息的住院病人,当仅剩骶部神经阻滞时可以回到护理病房。门诊手术病人最主要的是阻滞作用完全消失。
椎管内麻醉病人应证明有排泄能力,这是骶部交感神经消失的证据。当然,准备行走的病人,运动神经完全恢复是必须的。
接受踝部阻滞,臂丛和外周神经阻滞的病人,即使麻醉作用或感觉异常持续存在也可以离开。手臂和脚或使用吊带或用较厚的包扎,要进行保护以免受伤。病人需要提醒当阻滞作用消失时会有不适。因此要给予病人指导和开出口服镇痛药在开始出现不适时使用,因为疼痛在变严重之前最好治疗。
全麻病人可以在手术室或转运到PACU不久清醒。尽管病人看起来是清醒,有正确定向力的,但让病人离开之前还有很多标准要到达满意。生命体征在术前基线范围的15-20%是基本要求的。病人要有完整的gag 反射,有效地咳嗽,无困难进食液体。没有必要让病人在离开之前进食。强迫病人感到饥饿时进食不想吃的食物只会增加术后恶心呕吐的发生。如果病人只有轻度恶心,还没有达到进食几小口不引起呕吐和恶心增加的程度,坚持让病人进食是愚蠢的做法。如果一直不能进食液体,也可以考虑让病人离开,但必须提供书面的分步骤指导(如何联系机构和外科医生)。确保离院前体液足够是重要的。尤其是口腔手术病人,因为术后疼痛导致不能早期经口进食。
除非病人术前就不能行走或手术原因,病人应该在其他设备辅助下能够行走,并且不头晕。如果需要拐杖,不要认为病人术前已接受过指导,应该给予另外的指导。手术伤口应该已经止血,疼痛控制的满意。应该回到术前的定向力水平,即使有一点轻度的镇静残余也是可以接受的。
除非是在腹股沟或会阴区进行的泌尿生殖手术,妇科或其他相关的手术,没有必要让病人证明有排尿能力。病人和护送人员要被告知,如果离开恢复区后6h仍未排泄,要通知医院或外科医生。
已经开发了麻醉后允许离开评分系统,目的是评估术后何时达到准备离开的标准。如精神状态,疼痛程度,行走能力,数字评分的生命体征的稳定性等,总评分高于某个特定值说明进行离院准备的可能性高。从实用方面讲,评分系统因该易于理解,应用简单,并且客观。精确的书面神经生理学测试已经单独用来进行麻醉恢复程度的研究评估。事实上,生命体征恢复,能够独立行走和排尿或许是对麻醉后恢复程度及可以作离院准备粗略评估的最好指标。这些活动是运动强度,中枢神经系统,交感系统恢复的表现。
每个病人和护送人员应该给予一套详细的包括活动、用药、穿衣,限制沐浴的详细指导。病人和护送人员必须口述这些指导,并签字,病人不能时,护送人员代签。两个人都必须意识到当不良反应或任何其他困难如出血,头疼,严重疼痛,严重恶心,呕吐发生时,有联系医院的需要。术后并发症大多在病人离开后发生。因此,有必要确保病人或代为签字的护送能够人员充分理解上面所有的信息(表77.6)。
大部分机构强制规定,对接受过大于一种局麻药的病人要有负责人的成人陪伴才能离开。所谓“负责人成年人”定义现在已经放宽,包括空闲的未成年人或较大的儿童。理论上讲,陪伴人员应该健康并且能在术后第一个24小时和病人呆在一起。这对老年和虚弱病人尤其重要。如果一个八旬老人被他八旬的配偶陪伴下 被允许离开,就有出事的可能。儿童出院后可能突然出现恶心呕吐,疼痛,恐惧或定向力障碍,一个正在驾车的父母可能不能同时处理好孩子。
“适合在家”与“可以上街”有明显的区别。适于在家是达到可以从恢复区离开的标准。而“可以上街”是在24h后,当大部分细微的和持续存在的全麻对中枢神经系统的影响已纪完全消失后。必须建议病人在回家后不立即进行正常活动。
病人离开前必须达到标准,并在离开前刻作最后的评估。必须排除对对正常所有状态如生命体征和异常症状的所有干扰。
必须尽最大努力避免让病人过早离开PACU。错误判断的结果就是在它处的急救和在其他医疗机构的再入院。当对病人情况的稳定性或是否离开有疑问时,最好的办法就是过夜留置观察。
30. 门诊手术后意外住院的病人怎么处理?
尽管病人术后被允许回家,但还会因为很多原因入院。其中,与术后麻醉相关的约有1/4。其他的是医疗和手术因素(表 77.7)。
大多门诊手术机构意外再入院率在低于1%到大约4%不等。全麻较局麻或部位麻醉发生率高。可以想象,局麻附加静脉镇静增加发生率。恶心、呕吐、眩晕、支气管痉挛、延迟苏醒是常见麻醉相关再入院的原因。
31. 全麻后的病人何时能进行机动车驾驶?
当前建议全麻或接受静脉镇静的病人,术后以后的24-48h不操作重型机械,包括开车。在自己或他人看来已经完全恢复的病人,轻微精神运动性障碍或定向力障碍是持续存在的,这些行为应该推迟到术后第二天。但与警告相反,术后调查发现有一些病人在术后24h驾驶车辆,甚至直接开车回家。
病人也可能因为中枢神经系统紊乱或手术本身会有脚步较轻的感觉,甚至跌到。其中的一些和意识混乱或精神状态的变化有关。还有其他原因如眩晕或疼痛。也希望未来的麻醉药不再有后续的,潜在中枢神经系统功能不全的危险。
32.门诊手术病人术后恢复中心的地位是什么?
一些手术后,病人会有口服阿片类药物不能控制的术后疼痛。所以他们需要一些技术性的护理观察或特殊护理,这可以在急救医院外获得,并对病人和家人来说更便宜,舒适。带着这种理念,恢复护理医疗机构的概念诞生了,出现了一种新的住院病人术后监护单位。这种模式整合了需要过夜观察的门诊手术病人或延伸的出院后服务。例如子宫切除术,腹腔镜胆囊切除术,shoulder repairs, 乳房切除术。如果这种形式也不能得到,可使用合适的家庭服务包括控制疼痛的新模式也能让病人免去术后的过夜住院观察。
33.门诊手术质量能持续提高吗?
为了确保病人满意的服务质量,麻醉医生应该在术后一天对所有病人电话追踪服务。有些机构还有两项另外的服务,一个是手术当天夜里和术后一周。术后访问卡应该邮寄给病人,询问整个经历。要有空白地方让病人填写副作用或不良反应。依靠外科医生提供精确并发症反馈信息是不可靠的。因此,追踪服务机制必须进行,以发现和确认需要补救措施。


《完》
您的位置:医学教育网 >> 医学资料