Postanesthesia Discharge Scoring System Research Articles

Discharge criteria for day case surgery

Background With the development of day case surgery,a number of new scoring systems had been designed to help the doctors to evaluate whether and when to let the patients discharging home.But till now,globally standardized criteria for discharge after anesthesia have not been established.Objective This paper sums up literatures on the discharge criteria of day case surgery.Content This paper describes the Aldrete's scoring system,postanesthetic discharge scoring system,the discharge criteria after neuraxial blockade and regional anesthesia,and the factors that affect hospital stay.Trend Each scoring system has its own superiority.However,with the development of surgery and anesthesia,we need to formulate more in line with the status quo of discharge criteria of day case surgery. Key words: Day case surgery; Discharge criteria

Preoperative administration of controlled-release oxycodone as a transition opioid for total intravenous anaesthesia in pain control after laparoscopic cholecystectomy

The complexity of pain from laparoscopic cholecystectomy and the need for treating incident pain provide rationale for multipharmacological analgesia. We investigated the preoperative administration of controlled-release (CR) oxycodone as transition opioid from remifentanil infusion for pain after laparoscopic cholecystectomy. Fifty consecutive patients undergoing laparoscopic cholecystectomy were randomly, double-blindly assigned to treatment group (n=25, CR oxycodone: 1 h before surgery and 12 h after the first administration) or to the control group (n=25, placebo: administered at the same intervals). General anaesthesia was maintained with propofol and remifentanil target-controlled infusions (TCIs). All patients received ketorolac 30 mg i.v. Tramadol i.v. was administered for patient-controlled analgesia (PCA) postoperatively. Numerical rating scale for pain at rest and at movement (NRSr and NRSi), tramadol consumption, times to readiness to surgery and awakening, times to modified Aldrete's and modified Post-Anesthetic Discharge Scoring System (PADSS)>9 and side effects were evaluated. All NRSr and NRSi and tramadol consumption were significantly lower in the treatment group. The oxycodone group showed higher modified Aldrete's scores at each time and reached a PADSS>9 faster. Side effects and postoperative nausea and vomiting episodes were comparable. We demonstrated the success of a multipharmacological treatment including opioid premedication with CR oxycodone used as transition opioid for TCI remifentanil infusion; the treatment group showed lower pain scores and rescue analgesic consumption, shorter time to discharge from recovery room and from surgical ward, and the same incidence of side effects, comparably to controls.

Comparision of Total Intravenous Anesthesia and Sevoflurane-N2O-Alfentanil Anesthesia for Laryngeal Microscopic Surgery

Background: The aim of this study was to compare the clinical properties of sevoflurane-N2O-alfentanil with propofol- remifentanil anesthesia for patients undergoing laryngeal microscopic surgery. Methods: Sixty patients scheduled for elective ambulatory surgery received either total intravenous anesthesia (TIVA group) with remifentanil and propofol or balanced anesthesia with sevoflurane-N2O-alfentanil (sevoflurane-N2O-alfentanil group). The TIVA group patients were induced with an effective-site concentration of 4μg/ml propofol and a bolus dose of 0.5μg/ml remifentanil. The anesthesia was maintained with a continuous infusions with an effective-site concentration of 2-5μg/kg propofol and 0.05-0.5μg/kg/min remifentanil, according to the hemodynamic response. The sevoflurane-N2O-alfentanil group patients were induced with 5 mg/kg thiopental and 20μg/kg IV alfentanil. Maintenance was obtained with 1.5-3.0 vol% sevoflurane and a bolus dose of 10μg/kg IV alfentanil if needed. The anesthetic depth was controlled under bispectral index (BIS) monitoring: propofol and sevoflurane concentrations were adjusted to achieve target BIS values, and were between levels of 40-60 during surgery. Results: Both anesthetic methods provided acceptable hemodynamic responses during surgery. The late recovery times (postanesthetic discharge scoring system), patient satisfaction and postoperative side effects were similar between patients in the two groups. Early recovery times (eye opening and the aldrete score) were shorter in the TIVA group patients, but this difference was not associated with a shorter hospital length of stay. Conclusions: Total intravenous anesthesia with remifentanil-propofol and balanced anesthesia with sevoflurane-N2O-alfentanil both provided satisfactory anesthesia for laryngeal microscopic surgery.

Comparison of Remifentanil With Fentanyl for Deep Sedation in Oral Surgery

The aim of this study was to compare recovery for oral surgery patients given a deep sedation regimen of midazolam, propofol, and remifentanil with a standard control of fentanyl in place of remifentanil. This investigation was designed as a randomized, prospective, single-blinded controlled study. Group 1, the control, received midazolam 0.03 mg/kg, fentanyl 1 microg/kg, and propofol initially at 140 microg/kg/min. Group 2 received midazolam 0.03 mg/kg, remifentanil: propofol (1:500) given at an initial propofol infusion rate of 40 microg/kg/min. Outcome measures included time to response to verbal command, Aldrete score = 9, Postanesthesia Discharge Scoring System = 7, and assessment by the Digit Symbol Substitution Test. Forty-seven subjects were entered in the study. Baseline findings were homogenous between the 2 groups. Subjects in group 2 recovered earlier (P < .005) and required less propofol for both the induction (0.8 +/- 0.4 versus 1.2 +/- 0.6 mg/kg; mean +/- SD, P < .01) and maintenance of deep sedation (46 +/- 9 versus 131 +/- 17 microg/kg/min; P < .005). There were minor differences in vital signs. This study demonstrated that this remifentanil regimen provided significantly more rapid recovery and used significantly less propofol compared with the fentanyl regimen.

Postoperative Morbidities Following Dental Care Under Day-Stay General Anesthesia in Intellectually Disabled Children

The objective of this study was to compare the postoperative morbidities for 24 hours following dental care under day-stay general anesthesia using sevoflurane or halothane in intellectually disabled children. Eighty-six premedicated patients with intellectual disabilities underwent general anesthesia for their dental treatment. They were randomly given anesthesia maintained with sevoflurane (2% to 3%) or halothane (1% to 1.5%) after receiving inhalation induction either with sevoflurane (8%) or halothane (5%) and nitrous oxide in oxygen (50:50). The patients' age, gender, weight, ASA Class, type of dental treatment, and duration of anesthesia and operation were recorded as well as the time required for recovery (Aldrete Scale) and the length of time taken before they were discharged (postanesthetic discharge scoring system) from the hospital. Pain and agitation were recorded using a visual analog scale (0 to 10). Other postoperative morbidities, which include crying, nausea and vomiting, bleeding, and drowsiness, were also noted for 24 hours after the operation. The most common morbidities during the postoperative 24 hours were agitation and pain, and their occurrence was significantly more common in the sevoflurane group than in the halothane group (P < .05). The recovery time was shorter in the sevoflurane group, but it was not statistically significant. There was no difference between the groups in the discharge time. Apart from more postoperative agitation and pain after awakening from sevoflurane, the quality of recovery was similar for both sevoflurane and halothane.

Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery

Background and objective: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. Methods: Patients in Group 1 (n = 20) received alfentanil 20 μg kg−1 followed by 2 μg kg−1 min−1 intravenously; patients in Group 2 (n = 20) received remifentanil 1 μg kg−1 followed by 0.5 μg kg−1 min−1 intravenously. Both groups then received propofol 2 mg kg−1 followed by 9 mg kg−1 h−1 intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). Results: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score ≥9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores ≥9 were similar. Conclusions: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.

Comparison of total intravenous anesthesia and sevoflurane-fentanyl anesthesia for outpatient otorhinolaryngeal surgery

Study Objective: To compare the recovery characteristics of two widely used anesthetic techniques: remifentanyl-propofol and sevoflurane-fentanyl in a standardized ambulatory population. Design: Randomized, single-blinded study. Setting: University-affiliated medical center. Patients: 50 ASA physical status I and II patients undergoing elective ambulatory otorhinolaryngeal surgery. Interventions: Patients were randomized two groups to receive total intravenous anesthesia (TIVA group) with remifentanil and propofol or sevoflurane-fentanyl (SF group). TIVA patients received induction with propofol 1.5 mg/kg intravenously (IV) and remifentanil 0.5 μ/kg IV. The anesthesia was continued with a continuous infusion of propofol 100 μg/kg/min and remifentanil 0.0625–0.25 μg/kg/min. The SF group received, at induction, fentanyl 2 μg/kg followed by propofol 1.5 mg/kg IV. Maintenance was obtained with 1 to 1.5 minimum alveolar concentration of sevoflurane and bolus of fentanyl 1 μg/kg IV as needed. Measurements and Main Results: Early recovery times (eye opening, response to commands, extubation, orientation, operating room stay after surgery, and Aldrete score ≥9) and patient satisfaction were similar between the two groups. Postanesthetic discharge scoring system (PADSS) ≥ 9 was significantly shorter for the TIVA group (135.9 ± 51 vs. 103 ± 32 min) (p < 0.01) but this difference was not associated with a shorter postanesthesia care unit (PACU) length of stay. Conclusion: Early recovery times are comparable between total intravenous anesthesia and sevoflurane-based anesthesia. Even though patients in the TIVA group achieved home readiness criteria in a significantly shorter time, this technique does not shorten PACU length of stay, which depends instead on multiple nonmedical and administrative issues.

Continuous Thoracic Epidural Anesthesia with 0.2% Ropivacaine Versus General Anesthesia for Perioperative Management of Modified Radical Mastectomy

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5--10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1--2 mg of midazolam or 50--100 microg/mL of fentanyl followed by 50--150 mg of propofol and was maintained with sevoflurane and 50% N(2)O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

Remifentanil infusion facilitates early recovery for obese outpatients undergoing laparoscopic cholecystectomy.

D espite the well known adverse effects of obesity, it is still the most common nutritional disorder in the United States. Unfortunately, there is a paucity of data supporting the use of one anesthetic technique over another in obese (versus nonobese) patient populations. Prolonged emergence time from general anesthesia in obese patients can be problematic in the ambulatory setting because it can delay the early recovery process. Cork et al. (1) reported that the use of IV anesthetic and analgesic drugs does not guarantee a shorter emergence period in the obese population. Because remifentanil can reduce the required endtidal concentration of volatile anesthetics by up to 50% (2,3), we hypothesized that the use of a remifentanil infusion during a sevoflurane-based anesthetic would facilitate emergence from anesthesia in obese patients undergoing ambulatory surgery.

Discharge criteria and complications after ambulatory surgery.

I n recent years, the emphasis in providing surgical services has undergone remarkable change. Previously, patients undergoing surgical procedures remained in a hospital for many days after the operation. In 1994, 66% of all elective operations in the United States were performed on an outpatient basis (1). More complex ambulatory procedures are being performed on sicker patients (2). With the increased emphasis on early discharge after surgery and anesthesia, it is important to identify criteria that can be used to determine when patients can safely go home under the care of a friend or relative. In this article, we review current knowledge regarding the assessment of home-readiness after ambulatory surgery and discuss potential complications and appropriate treatment regimens.

Discharge Criteria and Complications After Ambulatory Surgery

Discharge Criteria and Complications After Ambulatory Surgery

Clinical application and comparison of home-readiness with two post-anaesthetic discharge scoring system

Clinical application and comparison of home-readiness with two post-anaesthetic discharge scoring system

A post-anesthetic discharge scoring system for home readiness after ambulatory surgery

A post-anesthetic discharge scoring system for home readiness after ambulatory surgery

A Post-Anesthetic Discharge Scoring System for home readiness after ambulatory surgery

Study Objective: To evaluate the validity and reliability of an objective scoring system, the Post-Anesthetic Discharge Scoring System (PADSS), which was compared against existing Clinical Discharge Criteria in the ambulatory surgery unit of our hospital. Design: randomized, open study. Setting: Ambulatory surgery unit at a university teaching hospital. Patients: 247 ambulatory surgery patients undergoing general anesthesia. Interventions: One hour after the operation, the initial assessment using PADSS and the Clinical Discharge Criteria was made by an independent observer. Evaluations were repeated at 30-minute intervals until patients obtained a Post-Anesthetic Discharge Score of at least 9 and fulfilled the Clinical Discharge Criteria. Measurements and Main Results: There was a close correlation between the end of anesthesia to time patients were fit for discharge using either PADSS or the Clinical Discharge Criteria (Pearson's Correlation Coefficient r = 0.89). The internal consistency reliability of PADSS (alpha = 0.65) was superior to that of the Clinical Discharge Criteria (alpha = 0.14). Conclusions: We have found PADSS to have superior measurement scaling and diagnostic properties.

Recovery Pattern and Home-Readiness After Ambulatory Surgery

Despite increased use of ambulatory surgery, few data exist regarding patient recovery patterns and home-readiness. We prospectively identified the pattern of home-readiness, the persistent symptoms after surgery, and the factors that delay discharge after home-readiness criteria are satisfied. Five hundred patients were scored by the same investigator using the Postanesthetic Discharge Scoring System (PADSS) every 30 min, commencing 30 min after surgery, until the PADSS score was > or = 9. The same investigator telephoned each patient 24 h after discharge to administer a standardized questionnaire so that postoperative symptoms could be identified. Eighty-two percent of patients were discharged 2 h and 95.6% 3 h after surgery. These patients could have been discharged earlier. After home-readiness criteria were satisfied, some patients had delayed discharge because of the unavailability of immediate escorts or the recurrence of pain. Persistent symptoms delaying discharge occurred in 4.4% of patients. Patients who underwent certain ambulatory surgical procedures, such as laparoscopy or orthopedic and general surgery, had a sixfold increased risk of developing persistent symptoms in the ambulatory surgery unit. The time to home-readiness was 2.5-fold longer and the incidence of 24-h postoperative symptoms, two- to eightfold higher in the group with persistent symptoms in the ambulatory surgery unit. In summary, periodic objective evaluation of home-readiness revealed that the majority of patients would achieve a satisfactory score on or before 2 h after surgery. The time to home-readiness by objective evaluation correlated with the type of surgery. Most delays after satisfactory home-readiness scores were reached were due to nonmedical reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery Pattern and Home-Readiness After Ambulatory Surgery

Despite increased use of ambulatory surgery, few data exist regarding patient recovery patterns and homereadiness.We prospectively identified the pattern of home-readiness, the persistent symptoms after surgery, and the factors that delay discharge after homereadiness criteria are satisfied. Five hundred patients were scored by the same investigator using the Postanesthetic Discharge Scoring System (PADSS) every 30 min, commencing 30 min after surgery, until the PADSS score was >or=to 9. The same investigator telephoned each patient 24 h after discharge to administer a standardized questionnaire so that postoperative symptoms could be identified. Eighty-two percent of patients were discharged 2 h and 95.6% 3 h after surgery. These patients could have been discharged earlier. After home-readiness criteria were satisfied, some patients had delayed discharge because of the unavailability of immediate escorts or the recurrence of pain. Persistent symptoms delaying discharge occurred in 4.4% of patients. Patients who underwent certain ambulatory surgical procedures, such as laparoscopy or orthopedic and general surgery, had a sixfold increased risk of developing persistent symptoms in the ambulatory surgery unit. The time to home-readiness was 2.5-fold longer and the incidence of 24-h postoperative symptoms, two- to eightfold higher in the group with persistent symptoms in the ambulatory surgery unit. In summary, periodic objective evaluation of home-readiness revealed that the majority of patients would achieve a satisfactory score on or before 2 h after surgery. The time to home-readiness by objective evaluation correlated with the type of surgery. Most delays after satisfactory home-readiness scores were reached were due to nonmedical reasons. Patients with persistent postoperative symptoms in the ambulatory surgery unit correlated with increased 24-h postoperative symptoms. (Anesth Analg 1995;80:896-902)

A postanaesthetic discharge scoring system for home readiness after ambulatory surgery

The assessment of a patient's home readiness is an important element in ambulatory surgery. No objective scoring system exists which systematically determines home readiness. A new postanaesthetic discharge scoring system (PADSS) has been designed and evaluated for reliability and validity against the existing clinical discharge criteria (CDC) in the ambulatory surgery unit of the hospital. Two hundred and forty-seven ambulatory surgery patients undergoing general anaesthesia were studied. Overall, there was a close correlation between the end of anaesthesia to the time patients were fit for discharge using either the PADSS or the CDC (Pearson's correlation coefficient r = 0.89). The internal consistency reliability of the PADSS (α = 0.65) was superior to that of the CDC (α = 0.14). The interobserver reliability coefficients of the PADSS at 1.0 and 1.5 h post surgery was also superior to the CDC for the dilatation and curettage patients. We have validated the PADSS against the CDC and found it to have superior measurement scaling and diagnostic properties.

Are discharge criteria changing?

The safe and expeditious conduct of ambulatory surgical care can succeed only by careful selection of patients and surgical procedures, appropriate intraoperative and postoperative anesthesia care, and prudent and timely discharge of patients. Practical discharge criteria or a postanesthesia discharge scoring system should be implemented in every ambulatory surgery center to ensure safe recovery and discharge after anesthesia. The PADSS is simple, practical, and easy to remember. It provides an uniform assessment of all patients, it may have added medicolegal value, and it establishes a routine of repeated reevaluation of home readiness. We recommend using the postanesthesia recovery score (Aldrete score) to evaluate the initial recovery of the patient. Once the Aldrete score is met, home readiness can be evaluated by the PADSS or modified PADSS (Tables 3 and 4). If the patient satisfies the criteria of the PADSS or modified PADSS, he or she can be discharged home. At the Toronto Hospital, we have discharged 30,000 patients home safely with the PADSS. However, any discharge criteria scoring system must be used with common sense and clinical judgment. Home readiness does not mean street fitness. Further studies on adverse outcomes after discharge and the return to normal function (e.g., work readiness) are warranted.