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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?
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)。
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。
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。
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)。
31. 全麻后的病人何时能进行机动车驾驶?
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。

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