Suzanne E. Rapp

Factors Affecting Discharge Time in Adult Outpatients

Discharge time (total recovery time) is one determinant of the overall cost of outpatient surgery.We performed this study to determine what factors affect discharge time. Details regarding patients, anesthesia, surgery, and recovery were recorded prospectively for 1088 adult patients undergoing ambulatory surgery over an 8-mo period. The contribution of factors to variability in the discharge time was assessed by using multivariate linear regression analysis. In the last 4 mo of the study, nurses indicated the causes of discharge delays >or=to50 min in Phase 1 or >or=to70 min in Phase 2 recovery. When all anesthetic techniques were included, anesthetic technique was the most important determinant of discharge time (R2 = 0.10-0.15; P = 0.001), followed by the Phase 2 nurse. After general anesthesia, the Phase 2 nurse was the most important factor (R2 = 0.13; P = 0.01-0.001). In women, the choice of general anesthetic drugs was significant (R2 = 0.04; P = 0.002). The three most common medical causes of delay were pain, drowsiness, and nausea/vomiting. System factors were the foremost cause of Phase 2 delays (41%), with lack of immediate availability of an escort accounting for 53% of system-related delays. We conclude that efforts to shorten discharge time would best be directed at improving nursing efficiency; ensuring availability of an escort for the patient; and preventing postoperative pain, drowsiness, and emetic symptoms. The selection of anesthetic technique and anesthetic drug seems to be of selective importance in determining discharge time depending on patient gender and type of surgery. Implications: The relative importance of anesthetic and nonanesthetic factors were evaluated as determinants of discharge time after ambulatory surgery. Postoperative nursing care was the single most important factor after general anesthesia; anesthetic drugs, anesthetic technique, and prevention of pain and emetic symptoms were of selective importance depending on patient gender and type of surgery. (Anesth Analg 1998;87:816-26)

Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery

The management of postoperative pain with continuous epidural fentanyl infusion was compared with continuous intravenous fentanyl infusion. In a randomized, double-blind protocol we prospectively studied 20 patients undergoing repair of the anterior cruciate ligament of the knee. The quality of analgesia and the incidence of side effects were documented. Compared with patients receiving continuous intravenous fentanyl infusion, at 18 h postoperatively patients given continuous epidural fentanyl infusion reported similar pain scores both at rest (22 ± 25 vs 27 ± 21 P = 0.52) and with ambulation (59 ± 18 vs 56 ± 22, P = 0.82). Plasma fentanyl levels were 1.8 ± 0.4 and 1.7 ± 0.4 ng/m.L (P = 0.91) for the intravenous and epidural groups, respectively. There were no significant differences in the incidence of nausea, pruritus, or urinary retention. There was no respiratory depression in either group. We conclude that when compared with continuous intravenous fentanyl infusion, continuous epidural fentanyl infusion offers no clinical advantages for the management of postoperative pain after knee surgery.

Comparison of desflurane with propofol in outpatients undergoing peripheral orthopedic surgery

This study was undertaken to compare desflurane with propofol anesthesia in outpatients undergoing peripheral orthopedic surgery. Data were combined from two institutions participating in a multicenter study. Ninety-one patients, ASA physical status I or II, were each randomly assigned to one of four groups. After administration of fentanyl (2 micrograms/kg) and d-tubocurarine (3 mg), intravenous propofol was administered to induce anesthesia in groups I and II and desflurane in groups III and IV. Maintenance was provided by desflurane/N2O in groups I and III, propofol/N2O in group II, and desflurane/O2 in group IV. Emergence and recovery variables, psychometric test results, and side effects were recorded by observers unaware of the experimental treatment. Patients in group II experienced less nausea than other groups (P = 0.002) despite this group having required more intraoperative fentanyl supplementation than groups III and IV (P = 0.01). Time to emergence, discharge, and psychometric test results were similar in all groups. Desflurane appears to be comparable with propofol as an outpatient anesthetic, facilitating rapid recovery and discharge home.

Epidural morphine provides greater pain relief than patient-controlled intravenous morphine following cholecystectomy

The management of postoperative pain today increasingly involves use of either epidural narcotics or intravenous (IV) patient-controlled analgesia (PCA) (1,2). Neither technique is without risk or undesirable side effects, such as pruritus, nausea, and urinary retention. Whereas epidural morphine requires vigilance to detect occasional respiratory depression (2), IV PCA requires expensive delivery systems subject to mechanical failure or human error (3). The few studies that have compared epidural to IV PCA morphine for the management of postoperative pain are limited because only a single dose of epidural narcotic was administered (4-6). Following lower extremity surgery, we found that epidural morphine provided greater patient comfort both at rest and with ambulation (7). Epidural morphine may thus be particularly advantageous to facilitate early joint mobilization. Postoperative pain following upper abdominal surgery is often increased with coughing. This effect may cause splinting and a reluctance to breathe deeply (8). The purpose of this report is to evaluate both the quality of analgesia and the incidence of side effects resulting from the management of postoperative pain with either epidural or IV PCA morphine in patients following cholecystectomy.

Hepatic Artery Embolization: Factors Predisposing to Postembolization Pain and Nausea

PURPOSE Analysis of preprocedural factors that may be helpful in predicting the severity of pain and nausea after hepatic arterial embolization (HAE) for liver neoplasms. MATERIALS AND METHODS During a 2-year period, 62 patients (33 men, 29 women) underwent 130 palliative lobar HAEs for unresectable liver neoplasms. The hepatic lobe was embolized with 150-250-microm polyvinyl alcohol particulates with or without lipiodol and/or chemotherapeutic agents. Postembolization pain was rated at rest and during movement with use of an 11-point verbal pain scale, and postembolization nausea was assessed with use of a four-point verbal scale, each at two separate time periods. Daily morphine use was also recorded. Primary analysis was made using the first embolization procedure. One-way analysis of variance and Spearman correlation coefficients were used to identify associated predictors. Plots of the outcomes versus the pre-embolization liver function tests and sensitivities and specificities were used to identify the strength of the associations for prediction purposes. A secondary analysis was performed in patients who underwent multiple embolizations. RESULTS No strong categorical predictors were found from the ANOVA on the severity of postembolization pain or nausea. There were significant (P < .05) associations between the pre-embolization liver function tests and the pain outcomes only. However, while these laboratory values demonstrate strong associations with resultant pain, they are not strong predictors of pain and morphine requirements for any individual patient. The morphine requirements were highly associated (P < .0001) with the pain scores at rest and with movement. The authors did not find significant differences on any of the pain outcomes or morphine requirements between the first and second embolizations. CONCLUSION Laboratory values and patient age are not predictors for the severity of postembolization pain and nausea. Postembolization pain is a significant complication and poses a continuing challenge to the physician with regards to patient management.

Vaso-vagal reactions in an ambulatory surgery center

This prospective study was undertaken to determine the incidence and factors predisposing to vaso-vagal reactions during venous cannulation in an ambulatory surgery population. In 141 ambulatory surgery patients, signs and symptoms of a reaction together with mean arterial pressure and heart rate were recorded at 1-min intervals during and for 6 min after venous cannulation. Overall, 10.6% of patients were symptomatic (95% confidence interval [CI] 6%-17%). The incidence was 16.6% (95% CI 8.4%-24.9%) in patients < or = 40 yr and 33.3% (95% CI 6.7%-60.0%) with a prior fainting history. Young age, duration or number of attempts at venous cannulation, and fainting history were independently associated with increased risk of a reaction (P < 0.03-0.004 by multiple repression analysis). Minimum mean arterial pressure was less in symptomatic patients than in those who were asymptomatic (58 mm Hg +/- 11.3 SD versus 82 mm Hg +/- 14.3 SD, P < 0.0001). We conclude that reactions occur commonly, particularly in the young or in patients with a history of fainting. Reactions are typically associated with significant hypotension that may require treatment.

Rebound hypertension and acute withdrawal associated with discontinuation of an infusion of epidural clonidine

A small percentage of patients with cancer pain suffer from refractory pain despite aggressive therapy. 1 Intraspinal administration of opioids and local anesthetic agents may be helpful in such settings, but their use may be limited by side effects such as motor block and hemodynamic instability. 2,3 Clonidine is a centrally acting α 2 -adrenergic agonist with established analgesic effects 4,5 and has synergistic effects with spinal opioids 6,7 and spinal local anesthetics. 8,9 Epidural clonidine produces analgesia by a spinal mechanism in patients after surgery and in those with cancer pain, 10 and it appears to be an effective treatment for severe cancer pain in patients for whom other treatments are ineffective. 11 Although the risk of acute withdrawal and rebound hypertension is well recognized with sudden cessation of systemically administered clonidine, 12 no such reports exist with regard to epidurally administered clonidine. We describe a case of acute withdrawal and rebound hypertension after abrupt cessation of epidural clonidine in a patient with intractable cancer pain.

Postoperative pain management in gynecologic oncology patients utilizing epidural opiate analgesia and patient-controlled analgesia☆

Intraoperative analgesia is the purview of anesthesiologists whereas postoperative pain is traditionally managed by surgeons. This series reports 19 months experience of anesthesiologists using epidural opiate analgesia (EOA) or patient-controlled analgesia (PCA) to treat postoperative pain in 302 patients following surgery for pelvic malignancy. For the 244 (81%) patients who received EOA, a lumbar epidural catheter was placed just prior to surgery, injected with local anesthetic for intraoperative analgesia, and injected with preservative-free morphine at appropriate intervals postoperatively to relieve pain. Fifty-eight patients (19%) used PCA which consisted of small self-administered boluses of intravenous narcotics. All patients were seen daily to ensure adequate analgesia and to treat side effects. Utilizing a 0-10 verbal rating scale (0 = no pain; 10 = worst pain imaginable), mean pain with EOA was 0.75 at rest and 2.6 with coughing. Mean pain ratings with PCA were 2.8 at rest and 5.0 during coughing. Side effects with EOA included nausea or vomiting (28%) and pruritus (20%). The only side effect of significance with PCA was nausea or vomiting (21%). All patients improved with treatment of side effects. Acceptance of these techniques is indicated by a steady increase in the number of gynecologic oncology surgical patients utilizing these modalities (50% at the outset to 87% currently).

RECOVERY AND DISCHARGE

The quality and speed of recovery from anesthesia and surgery are a reflection of the anesthetic management of the patient as well as the type and duration of surgery and inherent characteristics of the patient involved. The recovery process is also influenced by the skills and procedures employed by those overseeing care of the patient during recovery. This article focuses on the procedural aspects of recovery and individual factors that contribute to making a smooth transition from the operating room to home. 55,81

Attitudes and Beliefs of Working and Work-Disabled People with Chronic Pain Prescribed Long-Term Opioids

OBJECTIVE This study was designed to gain insight into the apparent contradiction between the perspectives of researchers and policy makers, who have questioned the efficacy and safety of chronic opioid therapy for non-cancer pain patients, and the patients themselves, who often indicate that the therapy has value. SUBJECTS A convenience sample of 54 patients on chronic opioid therapy was studied. METHODS Participants completed a questionnaire specifically designed for the study, and also several standard instruments that addressed functional interference, emotional functioning, and possible misuse of opioids. Their treating physicians rated the participants on the severity of their disability and the success of their opioid therapy. RESULTS Although participants reported significant ongoing pain, they gave positive global ratings to their opioid therapy, and reported little concern about addiction or side effects of opioids. They strongly endorsed the beliefs that opioids helped them control their pain and allowed them to participate in important activities such as work. They expressed the belief that their pain would be severe if they did not have access to opioids, and reported negative experiences with tapering or discontinuing opioids in the past. Work-disabled participants reported higher levels of affective distress, catastrophizing, and functional interference than working participants, and were judged by their physicians to be relatively less successful in managing their pain. CONCLUSION The results of this study suggest several tentative hypotheses about why patients on chronic opioid therapy value opioids, and identified several areas for systematic investigation in the future.