Postanesthetic Care Unit Discharge Research Articles

Safety and follow-up systems after ambulatory peripheral nerve block: a narrative review

Background: Ambulatory surgery has grown during the last decades, and Peripheral Nerve Blocks (PNB) are widely used for perioperative and postoperative pain management. Follow-up is required during all stages of recovery to assess adverse events. Patients are usually discharged before PNB effects have worn off, but next-day follow-up allows the detection of adverse events. Digital systems are used for different follow-up services, but knowledge is lacking in their use for PNB follow-up. Objective: This narrative review describes PNB-related adverse events and current ambulatory surgery follow-up practices during all recovery stages. Furthermore, this review will evaluate the methods used for PNB follow-up. Methods: A literature search was performed using SCOPUS, Embase, and MEDLINE databases from the earliest record to 01-03-2022. Articles were included if they assessed PNB-related adverse events, follow-up services for ambulatory surgery and PNBs, and outcomes for ambulatory surgery and PNBs. Articles were excluded if they studied non-surgical patients, were inaccessible or contained comments or letters. Results: 67 articles were included after screening. Three postoperative phases are described. Phase 1 encompasses the post-anesthetic care unit (PACU) stay. Phase 2 covers the time from PACU discharge to hospital discharge, and phase 3 starts after hospital discharge. The review shows that follow-up is provided adequately during the postoperative phases 1 and 2, but phase 3 lacks a proper follow-up. Possible complications for PNBs include pain, nausea and vomiting, dyspnea, neurological damage, and infection should be routinely evaluated postoperatively, preferably the day after discharge. Postoperative follow-up is often provided using a telephone call, but a lost-to-follow-up rate of up to 50% is described. Follow-up rates can be improved using digital follow-up systems, including automatic text messages and applications. Video consultations can be used to evaluate these complications. Conclusion: PNB postoperative follow-up after discharge is not well-provided. Telephone follow-up of PNB has a poor response. Digital follow-up systems, like automatic text messages and applications, can increase follow-up rates. Therefore, we recommend application-based follow-up systems. However, additional studies should evaluate the effect on patient outcomes.

Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis

AbstractBackgroundDexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half‐life of 2–3 hours might prolong recovery and discharge times when compared with an un‐supplemented propofol anesthetic. This may create an additional burden in a busy post‐anesthetic care unit (PACU).AimTo investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post‐procedural pain.MethodsWe conducted a retrospective review of outpatient procedures performed during a six‐month period including pediatric patients, ASA physical status I‐III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long‐acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups.ResultsCharts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non‐dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI −3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R2=0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per μg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay.ConclusionWe found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per μg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.

Application of a High-Flow Nasal Cannula for Prevention of Postextubation Atelectasis in Children Undergoing Surgery: A Randomized Controlled Trial.

General anesthesia-induced atelectasis is common, and persistent postoperative atelectasis is associated with pulmonary complications. We aimed to evaluate the preventive effects of a high-flow nasal cannula (HFNC) on postoperative atelectasis and respiratory complications in infants and small children. In this prospective randomized controlled trial, children (≤2 years) receiving general anesthesia (>2 hours) were randomized into the control and HFNC groups. At the end of the surgery, the first lung ultrasound evaluation was performed in both groups. In the postanesthetic care unit (PACU), the control group received conventional oxygen therapy, while the HFNC group received oxygen via HFNC, with a flow rate of 2 L kg-1 min-1. Before discharge to the ward, a second lung ultrasound examination was performed. The primary outcome was the lung ultrasound score at PACU discharge. The secondary outcomes included the lung ultrasound score at the end of surgery, the incidence of significant atelectasis at PACU discharge, and other postoperative outcomes. Lung ultrasound score and the incidence of atelectasis at the end of surgery did not differ significantly between the control (n = 38) and HFNC (n = 40) groups. After staying in the PACU, both groups showed a reduced lung ultrasound score and atelectasis incidence. However, the HFNC group had a significantly lower consolidation score than the control group (0; interquartile range [IQR] = 0-1 vs 3; IQR = 2-4; P< .001). Additionally, none of the patients had significant atelectasis in the HFNC group, compared to 6 patients in the control group (0% vs 15.8%; odds ratio [OR] = 0.444; 95% confidence interval for OR, 0.343-0.575; P = .011). Incidence of desaturation (oxygen saturation [Spo2] ≤ 95%), postoperative complications, and the length of hospital stay did not differ between the groups. Preventive use of HFNC after surgery improves the lung ultrasound score and reduces postoperative atelectasis compared to conventional oxygen therapy in infants and small children.

The analgesic efficacy of the transversalis fascia plane block in iliac crest bone graft harvesting: a randomized controlled trial.

BackgroundIliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting.MethodsFifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery.ResultsThe TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively.ConclusionsThe TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.

Estudo comparativo entre cetamina e morfina peridural em pacientes submetidas à mastectomia

JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi comparar a S(+) cetamina em relação à morfina associada à ropivacaína por via peridural torácica em operações de mastectomia. MÉTODOS: Estudo prospectivo com 26 pacientes com idade entre 18 e 70 anos submetidas à mastectomia, divididas em dois grupos de igual tamanho. As pacientes do Grupo M (morfina) receberam 12 mL de ropivacaína a 0,75% associadas a 2 mg de morfina sem conservantes, e as pacientes do Grupo C (cetamina) receberam 12 mL de ropivacaína a 0,75% associadas a 50 mg de S(+) cetamina sem conservantes. Foram avaliados os parâmetros hemodinâmicos, a necessidade de vasopressores, os fármacos para sedação, a escala analógica visual de dor nas primeiras 24 horas, consumo de analgésicos e de antieméticos e a incidência de náuseas e vômitos. RESULTADOS: Não houve diferença estatística entre os grupos em relação a dados demográficos, níveis de pressão arterial sistólica e diastólica, quantidade de anestésico local utilizado ou necessidade de vasopressores. O GC demandou maior uso de midazolam para controle da sedação (p = 0,0005). Este grupo apresentou menores escores de dor ao serem avaliados na alta da sala de recuperação pós-anestésica (p = 0,0018), após 12 horas do procedimento (p = 0,0001) e após 24 horas (p = 0,0094). O grupo morfina apresentou maiores escores de dor na sala de recuperação pós-anestésica, após 12 e 24 horas, demandando maior uso de analgésicos no pós-operatório (dipirona, p = 0,0009) assim como antieméticos (metoclopramida, p = 0,0032). CONCLUSÃO: Observou-se que a S(+) cetamina na dose avaliada foi segura e eficaz do ponto de vista hemodinâmico, apresentando melhor desempenho no controle de dor pós-operatória, gerando menor consumo de analgésicos, assim como menor incidência de náuseas e vômitos.

Renal function after laparoscopic cholecystectomy and analgesia with tramadol and dipyrone or ketorolac

Background: Laparoscopic cholecystectomy (LC) reduces surgical trauma and hospital stay, but requires effective and safe postoperative analgesia. This prospective and double-blind study investigated the effects of analgesia with tramadol combined with either dipyrone or ketorolac on the postoperative renal function of patients submitted to LC. Methods: Pre-and post-operatively (PO), estimated glomerular filtration rates (GFR), obtained by two formulas dependent on blood Cr and one on blood cystatin C values, and tubular enzymuria—alkaline phosphatase (AP), γ-glutamiltransferase (γ-GT)— were determined in well hydrated patients who underwent LC and analgesia with tramadol combined with either dipyrone (Dipyrone, n = 63) or ketorolac (Ketorolac, n = 63). Upon discharge from the post-anesthetic care unit (PACU), pain (through Verbal Numerical Scale—VNS) and need for rescue analgesia with morphine were evaluated. Results: There was hemodilution PO, which made GFR profile analysis more difficult—those dependent on Cr increased and statistically correlated, but those dependent on cystatin C did not change. There was a significant PO increase in AP in the Dipyrone and Ketorolac groups, and in the product of the both enzymes in the Ketorolac group. Upon PACU discharge, the Dipyrone group showed signifi cantly higher VNS scores than the Ketorolac group. All patients received morphine PO, and the total dose needed for pain control differed between groups, but without statistical significance. Conclusions: The association of tramadol with dipyrone or ketorolac in well hydrated patients submitted to LC had similar analgesic effectiveness in the PACU. Postoperatively, the effect on GFR may have been masked by hemodilution, and enzymuria was discreetly enhanced when ketorolac was used.

Isocapnic Hyperpnoea Shortens Postanesthetic Care Unit Stay After Isoflurane Anesthesia

We conducted a prospective controlled clinical trial of the effect of isocapnic hyperpnoea (IH) on the times-to-recovery milestones in the operating room (OR) and postanesthetic care unit (PACU) after 1.5 to 3 hours of isoflurane anesthesia. Thirty ASA grade I-III patients undergoing elective gynecological surgery were randomized at the end of surgery to either IH or the conventional recovery (control). Six patients with duration of anesthesia of <90 minutes were excluded from the analysis. The anesthesia protocol included propofol, fentanyl, morphine, rocuronium, and isoflurane in air/O(2). Unpaired t tests and analyses of variance were used to test for differences in times-to-recovery indicators between the two groups. The durations of anesthesia in IH and control groups were 140.8 + or - 32.7 and 142 + or - 55.6 minutes, respectively (P = 0.99). The time to extubation was much shorter in the IH group than in the control group (6.6 + or - 1.6 (SD) vs. 13. 6 + or - 3.9 minutes, respectively; P < 0.01). The IH group also had shorter times to eye opening (5.8 + or - 1.3 vs. 13.7 + or - 4.5 minutes; P < 0.01), eligibility for leaving the OR (8.0 + or - 1.7 vs. 17.4 + or - 6.1 minutes; P < 0.01), and eligibility for PACU discharge (74.0 + or - 16.5 vs. 94.5 + or - 14.7 minutes; P < 0.01). There were no differences in other indicators of recovery. IH accelerates recovery after 1.5 to 3 hours of isoflurane anesthesia and shortens OR and PACU stay.

Effect of daxapram on recovery following total intravenous anesthesia with propofol and remifentanil

Background: The aim of this study was to investigate the effect of doxapram on recovery following propofol-remifentanil anesthesia. Methods: Forty patients scheduled for gastrectomy were randomly allocated to receive either doxapram 1 mg/kg or normal saline at the end of surgery under propofol-remifentanil anesthesia. Clinical recovery from anesthesia was assessed by times to spontaneous breathing, eye opening on verbal command, extubation, and discharge from the postanesthetic care unit (PACU). Bispectral index (BIS) values, blood pressure, and heart rate were recorded every 2 min for 16 min after the administration of doxapram or saline. The incidences of side effects were checked in the recovery room. Results: Spontaneous breathing was recovered after 6.2 ± 1.1 minutes in the Doxapram group versus 9.2 ± 1.8 minutes in the normal saline group (P ＜ 0.001). Times to eye and extubation were also shorter in the Doxapram patients than in the normal saline patients (6.9 ± 1.0 and 8.1 ± 1.7 min versus 10.4 ± 2.0 and 12.0 ± 2.6 min, respectively) (P ＜ 0.001). However, the times to PACU discharge were not different between the two groups (46.9 ± 4.9 min versus 47.0 ± 6.0 min, respectively). The patients in the Doxapram group showed higher mean BIS values compared with the normal saline group during emergence, but there were no differences in arterial blood pressure, heart rate and incidences of side effects between the two groups. Conclusions: Doxapram 1 mg/kg hastens early recovery from TIVA with propofol and remifentanil, and this emergence effect correlates with higher BIS values. Doxapram, however, does not affect the discharge time from the PACU and incidences of side effects.

Financial and operational impact of a direct-from-PACU discharge pathway for laparoscopic cholecystectomy patients

We assessed the operational and financial impact of discharging laparoscopic cholecystectomy (LC) patients directly from the postanesthetic care unit (PACU) in comparison with post-transfer discharge from a hospital bed in a busy academic hospital. We retrospectively compared 6 months of performance (bed utilization; recovery room and hospital length of stay; complications; readmissions; hospital costs, revenue, and margin) after implementation of PACU discharges (case patients) to the corresponding 6 months in the prior year (control patients). After implementation, 66% of LC case patients were discharged on the day of surgery, compared with 29% in the control group (P < .05). Eighty percent of the day-of-surgery discharges were directly from the PACU. Shifting to PACU discharge saved 1 in-hospital bed transfer and 1 bed-day for each PACU discharge. Recovery room length of stay for PACU discharge patients was 26% longer than for hospital discharge patients (P = NS). Average hospital length of stay for all patients discharged on the day of surgery was 3.2 hours shorter (P < .05) for case patients (80% PACU discharge) than for control patients. There were no readmissions in the PACU discharge group and no difference in complications. While costs, revenue, and net margin for PACU discharge patients were reduced by 40% to 50% (P < .02) relative to floor discharge patients, the hospital's net margin for the combined case patient group was preserved relative to the control group. PACU discharge of LC patients significantly reduces bed utilization, decreases in-hospital transfers, and allows congested hospitals to better accommodate patient care needs and generate additional revenue.