华西小卒 发表于 2010-8-15 13:23:03

知识更新-门诊手术的麻醉 AMBULATORY SURGERY(双语)


Laurence M. Hausman, MD
James N. Koppel, MD
A 38-year-old woman is scheduled for an ambulatory diagnostic pelvic laparoscopy at 3 o’clock in the afternoon. She arrives 1 hour before scheduled surgery with her 11-year-old son and appears to be extremely apprehensive. Prior medical history is significant for asymptomatic esophageal reflux, long-standing stable asthma that has been successfully treated with inhaled sympathomimetics and steroids, and juvenile-onset diabetes mellitus, currently controlled with 25 U neutral protamine Hagedorn (NPH) and 6 U regular insulin every morning and 10 U NPH and 3 U regular insulin every night.
1.Are there advantages to performing surgery on an ambulatory basis?
2.Which patients are considered acceptable candidates for ambulatory surgery?
3.Are there any patients who should never have surgery on an ambulatory basis?
4.Are diabetic patients suitable candidates for ambulatory surgery?
5.What types of surgical procedures are appropriate for ambulatory surgery?
6.What is the appropriate fasting time before ambulatory surgery that necessitates an anesthetic?
7.Should drugs be administered to empty the stomach or change gastric acidity or volume before the administration of an anesthetic?
8.How can patients be appropriately screened for anesthesia when ambulatory surgery is planned?
9.What preoperative laboratory studies should be obtained before surgery?
10.Should an internist evaluate each patient before ambulatory surgery?
11.Is anxiolytic premedication advisable before ambulatory surgery, and what agents are appropriate?
12.What are the reasons for last-minute cancellation or postponement of surgery?
13.What is the ideal anesthetic for ambulatory surgery?
14.Are there relative or absolute contraindications to the administration of a general anesthetic in the ambulatory setting?
15.What are the advantages and disadvantages to performing a conduction anesthetic in the ambulatory patient?
16.What are the advantages and disadvantages of selecting a nerve block technique for the ambulatory patient?
17.Describe the intravenous regional anesthetic technique (Bier block) for surgery on the extremities.
18.What sedatives can be administered to supplement a regional anesthetic?
19.What complications of nerve block anesthesia are of special concern to the ambulatory patient?
20.Should patients having ambulatory surgery be tracheally intubated?
21.What is the role of propofol in ambulatory surgery?
22.What is total intravenous anesthesia (TIVA), and what are its advantages and disadvantages?
23.What is moderate sedation, when is it employed, and what advantages does it offer?
24.When tracheal intubation is required for a short procedure, can one avoid the myalgias associated with succinylcholine?
25.Can a relative overdose of benzodiazepines be safely antagonized?
26.Do the newer volatile agents offer advantages over enflurane and isoflurane?
27.What are the etiologies of nausea and vomiting, and what measures can be taken to decrease their incidence and severity?
28.How is pain best controlled in the ambulatory patient in the postanesthesia care unit (PACU)?
29.What discharge criteria must be met before a patient may leave the ambulatory surgery center?
30. What are the causes of unexpected hospitalization following ambulatory surgery?
31.When may patients operate a motor vehicle after receiving a general anesthetic?
32.What is the role of aftercare centers for the ambulatory surgery patient?
33.Are quality assurance and continuous quality improvement possible for ambulatory
1. 在门诊手术的优点在哪里?
2. 哪些病人可以接受门诊手术?
3. 哪些病人一定不能在门诊进行手术?
4. 糖尿病人适合门诊手术吗?
5. 门诊手术包括的种类有哪些?
6. 门诊手术麻醉合适的禁食时间是多少?
7. 麻醉前是否使用药物促进胃排空,改变胃液酸度和胃液量?
8. 怎么适当拒绝对已经安排门诊手术的病人进行麻醉?
9. 术前需要知道那些实验室检查结果?
10. 每个门诊手术病人都要进行内科评估吗?
11. 门诊手术前建议给抗焦虑药吗?哪些药物合适呢?
12. 最后一次取消或推迟手术的原因?
13. 什么是门诊手术的理想麻醉?
14. 有没有门诊手术全麻的相对或绝对禁忌证?
15. 对门诊手术施行部位麻醉的优缺点?
16. 对门诊手术选择神经阻滞的优缺点?
17. 描述四肢手术的静脉区域麻醉技术。
18. 哪些镇静药可以强化区域麻醉?
19. 门诊手术进行神经阻滞麻醉需要特别关注的并发症是什么?
20. 门诊麻醉需要气管插管吗?
21. 异丙酚在门诊麻醉的地位?
22. 什么是全静脉麻醉(TIVA),优缺点是什么?
23. 什么是适度镇静,给药时机和镇静的优点是什么?
24. 短小手术何时需要气管插管,能避免司可林相关的术后肌痛吗?
25. 相对大剂量的地西泮能被安全拮抗吗?
26. 新型挥发性麻醉药相对于安氟醚和异氟醚优越吗?
27. 恶心、呕吐的病因学是什么?哪些措施可以减少发生率和降低发作程度?
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?
30. 门诊手术后意外住院的病人怎么处理?
31. 全麻后的病人何时能进行机动车驾驶?
32. 门诊手术病人术后服务中心的地位是什么?
33. 门诊手术安全吗?质量能持续提高吗?

1.Are there advantages to performing surgery on an ambulatory basis?
There are multiple advantages to performing surgery on an ambulatory basis. Most obviously, the patient returns much more quickly to the familiar home environment. This is especially important for both pediatric and geriatric surgical patients. Formerly, patients might have remained hospitalized for days, rather than a few hours. A reduction in the acquisition of nosocomial infections has also been noted. This is an extremely important consideration when dealing with immunocompromised patients such as organ transplant recipients or patients who are receiving chemotherapeutic agents. Furthermore, in the ambulatory model, the incidence of medication errors related to either faulty prescribing or dispensing of drugs has decreased. In addition, overall costs are usually significantly reduced. This cost saving is due in part to a decrease in the number of laboratory tests requested and medical consultations obtained, as well as pharmaceuticals dispensed. Of course, the significant expense of both the inpatient hospitalization as well as the hospital facility fee is avoided. Other less tangible advantages include ease of scheduling procedures, without having to consider variables such as operating room block time, and an improved sense of patient privacy. This occurs because most offices are staffed by a small consistent group of personnel.
As a group, ambulatory patients tend to be more aware of the effects of the anesthetic they receive than the inpatient population. Because ambulatory patients usually undergo less intrusive surgical procedures and are less ill postoperatively, an attempt is made to resume usual preoperative activities at an earlier time. Therefore, nausea, vomiting, myalgias, headache, as well as disordered sensorium and vertigo may appear to be more significant to this group of patients. Unpleasant symptoms are spontaneously reported with greater frequency than in the inpatient group, and patients may tend to focus their attention on them. These discomforting symptoms, if present postoperatively, may be recalled in a vivid fashion if an additional surgical procedure is required. The negative recall may predispose the patient to extreme anxiety.
Only a small subgroup of patients may actually prefer hospitalization to ambulatory surgery.
1. 在门诊手术的优点在哪里?
2.Which patients are considered acceptable candidates for ambulatory surgery?
For patients to be considered acceptable candidates for ambulatory surgery, generally they should have a relatively stable medical condition. However, many centers now routinely accept American Society of Anesthesiologists (ASA) physical status III and IV patients for selected, relatively noninvasive surgical procedures or diagnostic studies. Generally, less invasive surgery is performed on patients who are less healthy, while more invasive surgery is performed only on ASA physical status I or II patients. Patients with cardiovascular disease have an increased risk of perioperative complications. Those with severe physical or mental handicaps are often excluded from consideration as candidates for ambulatory surgery. The ability to comprehend and comply with postoperative instructions is mandatory to the success of ambulatory surgery.
Ambulatory surgery is well suited for the pediatric patient population. Generally, ambulatory surgical procedures commonly performed on children are shorter in duration, less extensive, and less invasive than the majority of procedures performed on adults. Additional benefits to the pediatric group include less disruption of the child’s normal feeding schedule and decreased separation time from parents. Exposure to the unfamiliar and frightening hospital milieu can be reduced to the bare minimum. Additionally, because recovery times are short for procedures such as myringotomy and tubes, circumcision, and inguinal herniorrhaphy, early discharge from the facility is feasible.
Preoperative communication and collaboration between anesthesiologists and their surgical colleagues are essential in the case of the questionable or problem patient. The surgeon who is to perform the procedure, the patient, and the family must be agreeable to the concept of ambulatory surgery. However, reimbursement schedules created by insurance carriers will often convince the occasional skeptic, because costs associated with hospitalization for procedures that can be readily performed on an ambulatory basis will usually not be covered. Overwhelming and incontrovertible evidence of medical necessity for inpatient care must be presented to obtain authorization for postoperative hospitalization.
2. 哪些病人被认为可以接受门诊手术?
对认为可以接受门诊手术的病人,一般认为需要有相对稳定的医疗状况。事实上,很多中心常规接受ASA III-IV级的病人接受相对无创或诊断性检查。一般健康条件差的病人进行创伤小的操作,而只对ASA I – II级病人施行较大创伤的手术。伴有心血管疾病的可以增加围术期并发症。那些有身体或精神残疾的病人通常被排除在考虑之外。判断预后的综合能力是门诊手术成功的关键。

华西小卒 发表于 2010-8-15 13:23:56

3.Are there any patients who should never have surgery on an ambulatory basis?
An exception to the list of acceptable candidates is ex-preterm infants who are less than 55–60 weeks postconceptual age. These patients may have life-threatening episodes of postoperative apnea and bradycardia as many as 12 hours and up to 48 hours after receiving a general anesthetic. Therefore, in-hospital monitoring of these patients is recommended. For similar reasons, term infants less than 44 weeks postconceptual age should also have surgery performed only on an inpatient basis. Postoperative respiratory monitoring is mandatory for at least 12–18 hours. If at all possible, any required surgery or diagnostic procedures requiring the administration of either a sedative or a general anesthetic should be postponed until the child passes this period.
4.Are diabetic patients suitable candidates for ambulatory surgery?
Diabetic patients may present a major challenge for the anesthesiologist when scheduled for ambulatory surgery. Because of the critical nature of glucose homeostasis, it may be advisable to handle exceptionally brittle diabetics on an inpatient basis. Preoperatively, diabetic patients must be carefully assessed for the presence of end-organ damage. Cardiovascular disease, autonomic and renal insufficiency, and gastroparesis may lead to potential problems in the perioperative period.
It is preferable to schedule surgery on the insulin-dependent diabetic as the first or second case of the day. The major concerns, of course, are to avoid the extremes of plasma glucose, both hypoglycemia and hyperglycemia, as well as acidosis. Delays in insulin administration may lead to ketoacidosis despite the fasting state. For this reason, it is recommended that patients receive insulin along with a continuous infusion of dextrose on arrival at the ambulatory surgery facility. Insulin may be administered by either the subcutaneous or intravenous route. The relative advantage, if any, of administering a continuous infusion of regular insulin versus one third to one half of the usual long-acting insulin dose subcutaneously has not been demonstrated. Another option for early-morning surgical procedures is to administer the usual long-acting insulin dose subcutaneously immediately following surgery and shift the time of all meals and future insulin injections by the same offset.
Non-insulin-dependent diabetics who are controlled by one of the available oral hypoglycemic agents must also be carefully monitored in the perioperative period by periodic fingerstick or blood glucose determinations. The half-life of some of the oral agents may be as long as 60 hours (chlorpropamide). Fortunately, patients with adult-onset, non-insulin-dependent diabetes mellitus (NIDDM) rarely develop ketoacidosis. However, this group may develop hyperosmolar, nonketotic coma when significant hyperglycemia and dehydration occur.
Before discharge, it is critical that diabetic patients be capable of eating and be relatively free of significant nausea that might lead to emesis and inability to maintain adequate caloric intake.

5.What types of surgical procedures are appropriate for ambulatory surgery?
Initially, it was believed that procedures should be limited to those that could be easily accomplished within 1–11/2 hours. This was based on the premise that recovery time would be significantly prolonged after the administration of a lengthy general anesthetic and would perhaps prevent discharge. However, it has been well demonstrated that patients may be discharged safely and on a timely basis even after long operations performed with general anesthesia.
The types of surgical procedures that may be performed on an ambulatory basis will depend on whether an ambulatory surgery facility is truly a freestanding unit (geographically detached from a hospital) or is located within a hospital, or directly contiguous to an inpatient facility. Hospital-based units often accept patients with a greater severity of baseline illness and may perform more complex surgical procedures for a number of reasons. In the event of an unexpected massive surgical hemorrhage, availability of immediate blood bank support is crucial. However, when the need for blood may be anticipated preoperatively, even freestanding ambulatory surgery centers can arrange for blood products to be available, and transfusions may be administered if the need arises. Patients may also be asked to donate one or more units of autologous blood, which may be kept available for either intraoperative or postoperative use. Procedures in which blood might be administered include extensive liposuction or reduction mammoplasty. Radiology services, as well as subspecialty consultative services and the relative ease of hospital transfer for overnight admission, allow performance of more involved and invasive procedures in hospital-based ambulatory surgical facilities.
Ideal procedures for ambulatory surgery result in relatively minor postoperative physiologic changes including fluid shifts and blood loss. Commonly performed surgeries include procedures from all surgical disciplines and subspecialties. A few examples include cataract extraction, minor breast surgery, plastic surgery, dilatation and curettage, hysteroscopy, termination of pregnancy, laparoscopy, arthroscopy, inguinal and umbilical herniorrhaphies. The common denominator of all the procedures is that they are associated with only mild-to-moderate degrees of postoperative pain, which may be readily controlled by oral analgesic agents.
In the early days of ambulatory surgery, tonsillectomy was an example of a procedure that was considered to require overnight in-hospital observation. Today, it is being performed on an ambulatory basis in many centers, although the period of postoperative observation is increased compared with that for other ambulatory surgeries. After tonsillectomy, nausea and vomiting are the most common complications causing morbidity. Early bleeding, if it occurs, usually becomes evident within the first 6 hours. Therefore, it is now considered safe to discharge individuals to home who are otherwise in good health and reside within a reasonable distance from the facility with responsible adults. It is especially important that adequate fluid repletion be accomplished before discharge because early attempts at fluid intake after tonsillectomy may be relatively unsuccessful as a result of marked pharyngeal pain.

6.What is the appropriate fasting time before ambulatory surgery that necessitates an anesthetic?
The prescribed preoperative fasting period for both fluids and solids for patients scheduled for ambulatory surgical procedures should be identical to that required for an inpatient who is scheduled to receive an anesthetic. The ASA have released guidelines that recommend 8 hours for solids, 6 hours for a light meal (toast and tea), 4 hours for breast milk, and 2 hours for clear liquids. Eight ounces of orange juice without pulp or coffee without milk has not been demonstrated to increase gastric volume. In fact, both resting gastric volume and acidity may be reduced, which may further decrease the incidence and potentially devastating sequelae of an intraoperative aspiration.
Other benefits result from decreasing the fasting time in preoperative patients. Patients allowed to drink clear fluids are more content while they impatiently wait for a surgical procedure that was either delayed or was scheduled for the latter hours of the day. Thirst is relieved, and hunger may be diminished. Furthermore, the ingestion of glucose-containing solutions may also prevent relative degrees of hypoglycemia noted in both healthy patients and those with limited reserves. It is important to emphasize that medications required for the maintenance of homeostasis such as blood pressure and cardiac drugs can be taken orally up to 1 hour before surgery with an ounce of water.
Fasting guidelines should not be made on a case-by-case basis but rather should be reflected in facility- or institution- wide guidelines.
7.Should drugs be administered to empty the stomach or change gastric acidity or volume before the administration of an anesthetic?
Studies regarding differences in the resting gastric volume between the inpatient and ambulatory population have yielded conflicting results. Whereas some anesthesiologists administer liquid antacids before the induction of anesthesia, no evidence supports the notion that every patient must receive a soluble agent (0.3 molar sodium citrate, 30 ml). A soluble antacid is substituted for the conventional nonabsorbable antacid containing aluminum, magnesium, or calcium hydroxide to avoid the severe chemical pneumonitis that may result from aspiration of these particulate substances. Other pharmacologic agents include the H2-receptor blockers (ranitidine or famotidine), which inhibit gastric acid production and decrease gastric volume. Mental confusion has been reported after intravenous administration of cimetidine in geriatric patients. Ranitidine is more potent and specific and has a longer duration of action than cimetidine. Metoclopramide increases the tone of the lower esophageal sphincter as well as facilitating gastric emptying. However, it does not guarantee a stomach free of gastric contents. It also possesses anti-emetic properties. Metoclopramide, in conjunction with an H2-receptor blocker, may be more efficacious. However, the routine use of any of these drugs in patients without specific risk factors is not currently recommended.
Diabetes mellitus with evidence of autonomic dysfunction or gastric atony, documented hiatal hernia, a history of symptomatic gastroesophageal reflux, pregnancy, significant obesity, acute abdomen, or current opioid use or abuse are examples of diseases or conditions that appear to increase the incidence of aspiration during induction or emergence from general anesthesia or during heavy sedation. Therefore, prophylaxis in these situations is recommended. There is no advantage to administration of triple prophylaxis with H2-receptor antagonists, soluble antacids, and metoclopramide. If prophylaxis with an H2-blocker is employed, it should be given 1–2 hours preoperatively. Another effective regimen combines metoclopramide on the morning of surgery and a nonparticulate antacid immediately prior to surgery.
Despite the administration of pharmacologic agents and imposition of fasting, significant amounts of acidic gastric contents may still be present. Fortunately, aspiration of gastric material remains a relatively rare occurrence. If a patient is observed to aspirate and if symptoms of cough, wheeze, or hypoxemia while breathing room air do not develop within 2 hours, the development of significant respiratory sequelae is unlikely. Therefore, reliable and otherwise healthy ambulatory patients can probably be discharged after several hours of observation in the postanesthesia care area with the proviso that they immediately contact their physician at the onset of any symptoms.
8.How can patients be appropriately screened for anesthesia when ambulatory surgery is planned?
In the ideal situation, on the day before surgery a patient having an ambulatory procedure would have the opportunity to participate in a private conference with the anesthesiologist who will be caring for him or her. Rapport and trust could be established, and history and physical assessment could be conducted. Furthermore, appropriate laboratory tests could be ordered and additional consultations, if deemed necessary, could be requested. Finally, information from old medical records could be obtained.
To avoid an additional trip for the patient and family, some facilities may substitute a screening telephone interview for a personal interview, conducted by either a nurse or an anesthesiologist several days before surgery. Pertinent medical history can be elicited, general and specific instructions can be given, and reassurance offered to the patient. In this scenario, laboratory studies and additional components of the data base including an electrocardiogram (ECG) and radiographs, if necessary, are performed immediately before surgery. Previously established criteria will determine the tests that must be obtained. Of course, on the day of surgery the anesthesiologist must still review all information with the patient, conduct the appropriate examination, and obtain informed consent.
The surgeon who schedules surgery must assume a large degree of responsibility for the medical evaluation of the patient. The surgeon is often the only physician to see the patient until the day of surgery. Besides conducting a thorough history and physical examination, the surgeon may also request medical consultation when appropriate.
To aid in the screening process, surgeons may also selectively order laboratory and other examinations according to written guidelines established by the medical facility. However, a mechanism should be in place for free communication between the surgeon’s office and the facility so that appropriate action may be taken when abnormal laboratory values or other reports are received.
The anesthesiologist’s preoperative interview should be conducted in a relaxed, unhurried, and comprehensive manner both chronologically and geographically apart from the operating room. It is highly improper to conduct the preanesthesia interview and examination with the patient stripped of clothing and strapped to the operative room table. At this moment, the patient’s anxiety level may be extraordinarily high. Therefore, the patient may neglect to communicate essential information that may have an impact on either general medical care or intraoperative anesthetic management. Under these circumstances, it is truly impossible to obtain informed consent for anesthesia, which is a moral as well as a legal necessity. Additionally, with the surgeon and nurses waiting and instrumentation prepared, the pressure on the anesthesiologist to proceed with anesthesia may be intense.
The anesthesiologist should not fail to question patients firmly regarding the use of illicit drugs. In one patient population, one quarter of the subjects were found to have positive urine findings for commonly abused substances. Depending on the drug involved, modifications in patient management including cancellation of surgery might be well advised. Additionally, users of illicit drugs may have diminished capability or interest in complying with postoperative instructions.

9.What preoperative laboratory studies should be obtained before surgery?
For an ambulatory surgery unit that is affiliated with or attached to a hospital, clinical laboratory testing guidelines should be identical to those required by the related institution. It has been well established that shotgun, nonselective screening batteries of both laboratory, radiographic, and other studies yield an extraordinarily low rate of abnormal findings, few of which may have a significant impact on patient management. Patients scheduled for surgery should have preoperative testing ordered with selectivity and based only on a screening including a careful history and physical examination. In fact, indiscriminate ordering of tests can have potentially serious and deleterious consequences. To explain abnormal results, additional series of tests may be obtained. Some invasive studies have inherent dangers. Often, abnormalities are simply ignored, creating a potential medicolegal liability. Indiscriminate screening often reveals abnormalities that fail to have any relevance to either the surgery or the choice of anesthetic agent or technique. Some centers use handheld computers to obtain the patient history. Branching lines of questioning dependent on previous answers allow extensive information to be gathered. At the conclusion of the interactive interview, the computer can provide a detailed printout of significant findings in the history and recommend the preoperative testing to be obtained. Many facilities do not require any preoperative testing for superficial surgical procedures on otherwise healthy men and women below the age of 40–50 years.
10.Should an internist evaluate each patient before ambulatory surgery?
The same rules and standards regarding a complete preoperative evaluation of patients apply to surgery scheduled on either an inpatient or an ambulatory basis. Accordingly, an internist or medical subspecialist should be consulted regarding the advisability of surgery at a particular moment in time whenever the stability of a patient’s medical condition is questionable. Although it may be true that the resultant physiologic perturbations associated with some ambulatory surgery procedures may be characterized as minor, there is nothing minor about the administration of an anesthetic. A complete written history and physical examination are required as part of the medical record before the administration of anesthesia and commencement of surgery. For patients with no or stable co-existing medical conditions, the complete history and physical can be done by the surgeon. However, for patients with significant co-existing medical diseases and/or whose medical status may be questionable, there should be an evaluation completed by the internist or medical subspecialist.

11.Is anxiolytic premedication advisable before ambulatory surgery, and what agents are appropriate?
Because the goal of anesthesia for ambulatory surgery is to permit early discharge to home, there was concern that the administration of short-acting anxiolytic or analgesic premedication might delay recovery from anesthesia and thereby prolong time in the postanesthesia care unit (PACU) with a resultant delay in patient discharge. However, no significant differences in recovery times can be demonstrated after short-acting premedicants have been administered. The effects of more potent and longer-acting anesthetics and the surgical procedure itself contribute in a more significant fashion to the recovery time before a patient may be discharged. However, although time to discharge, a gross measurement, may remain unaffected, tasks that require fine coordination and speedy reaction times may still be deleteriously affected.
Many patients experience anxiety in the immediate preoperative period, and pharmacologic management is quite acceptable. The administration of either diazepam, 5–10 mg orally, 1–2 hours before surgery or midazolam, 1–2 mg intravenously, after an intravenous catheter is placed before surgery can ameliorate distress if deemed desirable. The amnestic effect of intravenous midazolam is powerful, and patients may not remember having seen their surgeon. Midazolam can also be given orally, although much larger doses are required because of first-pass hepatic degradation (0.5–1 mg/kg orally). Opioid premedication may contribute to the incidence of postoperative nausea and vomiting.
Preoperative oral doses of clonidine, a centrally acting a2-adrenergic agonist have been used to provide sedation, reduce anesthetic requirements, and decrease episodes of hypertension and tachycardia during intubation and maintenance of anesthesia. Side-effects of this class of drugs may include dryness of the oral cavity, hypotension, as well as undesirable sedation extending into the postoperative period. Relaxation techniques have been taught preoperatively to patients and may aid in the reduction of anxiety level. Instruction of these techniques, however, is time-consuming and requires patient motivation, and is therefore usually reserved for selected patients with extreme phobias.

12.What are the reasons for last-minute cancellation or postponement of surgery?
The incidence of last-minute postponement or cancellation of ambulatory procedures exceeds the cancellation rate for the inpatient population. A multiplicity of factors can be operative. Repeat physical examination by the surgeon may reveal the disappearance of pathology. Patients may forget and ingest either solid food or liquids before arrival at the medical facility. Abnormal results on tests that were not available or not previously reviewed may be discovered. Communication between the surgeon and anesthesiologist regarding laboratory abnormalities will help to reduce the incidence of last-minute cancellation of surgery, the consequences of which distress both patient and surgeon and make for inefficient use of available operating room time. Additional questioning may reveal either new symptoms or significant history that was not previously elicited. Physical findings apparent on a last-minute assessment by the anesthesiologist may preclude the safe administration of an anesthetic. Examples include an acute upper respiratory tract infection or an exacerbation of bronchospastic pulmonary disease. Finally, patients may arrive late to the facility or without a responsible escort to accompany them home.
Because the escort’s function in the postoperative period goes beyond merely ensuring a safe means of transportation home, in the absence of a designated appropriate escort, surgery should not proceed unless alternative care arrangements are made. If the patient speaks only a foreign language, the escort may serve as an interpreter throughout the perioperative period. After surgery, the escort will receive the postoperative instructions and serve as a companion to the patient during the first 24 hours following the completion of surgery. Assistance in the performance of activities of daily living will be rendered as required. Additionally, the escort will be available to summon medical assistance in the event of a medical, surgical, or anesthetic complication.

13.What is the ideal anesthetic for ambulatory surgery?
No single anesthetic is ideal for every procedure performed. However, the goal of the anesthetic is to allow for patient discharge shortly after the procedure’s completion. An ideal general anesthetic agent would have a rapid onset, permit a rapid return to baseline levels of lucidity and equilibrium, and be free of deleterious cardiovascular and respiratory effects. It would provide intraoperative amnesia, analgesia, and muscle relaxation and would possess anti-nausea and anti-emetic properties. Unfortunately, such a marvelous single agent is not in existence at the present time. In an attempt to avoid some of the unpleasant side-effects associated with general anesthesia, regional anesthetic techniques including field blocks, intravenous regional block (Bier block), various approaches to the brachial plexus, ankle block, and spinal and epidural anesthesia have been offered to patients as an alternative to general anesthesia.

14.Are there relative or absolute contraindications to the administration of a general anesthetic in the ambulatory setting?
Sometimes the administration of a general anesthetic clearly should be avoided, if possible. Examples of such cases are a patient with severe, poorly controlled asthma or documented bullous emphysema. In these cases, lesser concern should be given to the possibility of a postdural puncture headache (PDPH) if more serious sequelae are likely to result during or after administration of a general anesthetic. This, however, is the exception rather than the rule, and in most instances the final choice of anesthesia should remain with the patient, guided, of course, by the anesthesiologist. Additionally, when a patient arrives for extremely minor surgery without an escort, a local anesthetic injection alone might suffice for anesthesia. This might allow the patient to return home unaccompanied. Unfortunately, it sometimes becomes necessary to supplement a local anesthetic with intravenous sedation, and under these circumstances an escort would then be mandatory.

15.What are the advantages and disadvantages to performing a conduction anesthetic in the ambulatory patient?
Employing regional anesthesia in the ambulatory surgery patient has a number of potential advantages. If little or no intraoperative sedation is required, little or none of the “hangover” effect will be present throughout the postoperative period. Patients who express fear about losing consciousness or the loss of control associated with a general anesthetic may prefer a regional technique. Some patients have a strong desire to remain awake to view arthroscopic surgery as it is being performed.
Spinal or epidural anesthesia, however, has potential disadvantages. There had been concern regarding the apparent increased incidence of PDPH in patients who ambulate postoperatively. However, experience has shown that the incidence of PDPH is equal among patients who are nonambulatory and ambulatory, but that the onset may be delayed in patients who remain recumbent for a longer period of time. If spinal anesthesia is chosen, the use of conventional smaller gauge needles as well as newer designs (Greene, Sprotte, Whitacre) that include modifications at the tip to be less traumatic appear to markedly reduce the incidence of PDPH. The theory behind the pencil-point Greene, the conical Sprotte, or side port Whitacre needles is that splitting rather than cutting of the dural fibers occurs, which may reduce the amount of cerebrospinal fluid (CSF) leak.
Reduction of the incidence of PDPH to approximately 1–2% or less would be an ideal goal. Technical failure rates of the various needles must also be figured into the overall equation.
Patients must always be informed regarding the potential for development of a PDPH because ambulatory patients usually expect to resume their normal activities shortly after surgery. Additional recommendations to reduce the incidence of headache include keeping the bevel edge of the conventional needle parallel to the longitudinal axis of the body and the dural fibers and avoiding multiple attempts at subarachnoid needle placement. Maintenance of adequate hydration intraoperatively and postoperatively and avoiding straining and lifting postoperatively are recommended.
Patients presenting with a persistent PDPH may require an epidural blood patch for relief. Therefore, it is especially important to follow up patients with a telephone call at 24–48 hours after surgery to inquire about the presence of any problems. Conservative treatment of a PDPH in the ambulatory patient includes traditional analgesics, fluids, and bed rest. Performance of an epidural blood patch should be considered early if the headache is perceived by the patient to be extraordinarily severe or incapacitating, or if the patient must return to work immediately, or care for children.
In an attempt to avoid the possibility of a PDPH in younger patients, an epidural anesthetic may be offered to patients if a regional technique is requested or medically indicated. Though an epidural requires greater technical expertise and may be slightly more time-consuming to perform when compared with a spinal, the insertion of a catheter allows additional incremental doses of anesthetic to be added if surgical time is unexpectedly lengthened. Additionally, the use of shorter-acting local anesthetics allows for timing the block to wear off shortly after the procedure is completed. However, the incidence of headache after unintended dural puncture with larger gauge epidural needles is significantly higher. It is interesting that the reported incidence of headache following a general anesthetic in ambulatory patients exceeds the incidence of headache after regional anesthesia, although it is usually much less incapacitating and is self-limiting. It is postulated that the cause of the headache is intraoperative and postoperative starvation and an element of dehydration.
Spinal anesthesia provided by tetracaine and bupivacaine has been associated with recovery room stays as long as 6–8 hours. This must be considered before performing a regional anesthetic, especially if the procedure is to be done later in the day. Another potential disadvantage of administering a spinal anesthetic in an ambulatory patient is the potential for persistence of autonomic blockade for 1–2 hours following restoration of motor function. This can result in the inability to urinate and the need for bladder catheterization. It appears that increasing duration of sympathetic blockade correlates with an increased incidence of urinary retention.

椎管内麻醉存在潜在的缺点。有担心门诊手术后PDPH发生率增加。而实际,经验显示门诊病人和非门诊病人PDPH的发生率相等,但是较长时间的卧床将会延迟PDPH的出现时间。如果选择蛛网膜下腔阻滞,使用比传统型号较小的或新型设计的(Greene, Sprotte, Whitacre)包括尖端改进可以减少创伤的穿刺针可以显著减少PDPH发生率。铅笔尖后的Greene理论,圆锥形的Sprotte针或侧面缺口的Whitacre针都可以减少脑脊液(CSF)的外漏。

华西小卒 发表于 2010-8-15 13:30:15

本帖最后由 华西小卒 于 2010-8-15 13:33 编辑

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.
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.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.
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.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.
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.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.
31. 全麻后的病人何时能进行机动车驾驶?

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.
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.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.

《完》(丁香园 hillpeng)

hwjpg 发表于 2010-8-26 15:25:08


刁洁冰 发表于 2012-11-8 13:15:06


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麻醉春哥 发表于 2014-7-18 21:47:32


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Liuyanan2n 发表于 2015-3-18 11:59:48


杏林仙 发表于 2015-3-20 00:57:36

非常系统的介绍,真好! 学习了!

parkjo 发表于 2015-4-23 11:00:14


liweimax 发表于 2015-9-29 12:54:57

门诊手术 大势所趋啊

sas182227 发表于 2016-3-15 21:49:33


sas182227 发表于 2016-3-15 21:56:10


candy9585 发表于 2016-8-26 17:27:54

求问 这是什么书 求77.6表 谢谢

jerryzhjj 发表于 2016-12-16 14:08:38


jerryzhjj 发表于 2016-12-16 14:20:03

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