Factors affecting discharge time in adult outpatients.

UNLABELLED: 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 =50 min in Phase 1 or > or =70 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.

A multidimensional comparison of morphine and hydromorphone patient-controlled analgesia.

Although patient-controlled analgesia (PCA) pumps have been in use for more than a decade, the optimal PCA analgesic has yet to be identified. Many drugs are used; however, morphine remains the "gold standard" of opioid analgesics worldwide. The present study evaluated morphine and hydromorphone (Dilaudid) PCA with respect to analgesic efficacy, side effects, mood, and cognitive function. Sixty-one opioid naive patients undergoing lower abdominal surgery participated in the double-blind protocol. Verbal rating scores, use of medication, and side effects for the two medications were recorded. Cognitive functioning was assessed by computation of Digit Symbol and Trails Making B Tests. Self-reported affective state (mood) was measured by Profile of Mood States (POMS) inventory. Both medications provided adequate analgesia without a difference in side effects. Cognitive performance was poorer in the hydromorphone group (P < 0.05). Patients receiving hydromorphone reported less anger/hostility (P < 0.01) and generally better mood elevations on the other subscales than those receiving morphine. A similar incidence of side effects and dose medication can be anticipated with morphine and hydromorphone. When considering cognitive effects, morphine had less adverse consequences, while hydromorphone appeared to result in improved mood. We conclude that hydromorphone may provide a suitable alternative to morphine.

Acute pain management of the chronic pain patient on opiates: a survey of caregivers at University of Washington Medical Center.

OBJECTIVE: The provision of acute pain management for the chronic pain patient can pose a challenge. We sought to characterize management issues. SUBJECTS/SETTING: An anonymous survey was distributed to 270 physicians and 212 nurses at University of Washington Medical Center (UWMC) in an attempt to characterize management issues. DESIGN: Caregivers were queried regarding treatment modalities, efficacy of anxiolysis, patient attributes, concern of the quantity of medication, criteria for patient evaluation, and other management issues. RESULTS: Of the respondents, 61.8% were physicians, and 38.2% were nurses. The mean duration in practice was 7.7 years. The responses from the two groups were similar. Seventy-five percent reported using different pain-evaluation techniques for chronic pain patients than those utilized for the "average" patient. Pain scores were used frequently in the average patient, whereas ability to perform activities was used more commonly in the chronic pain patient (p < 0.0001). Half of the respondents expressed concern regarding the amount of medication used and level of sedation. The same proportion found anxiolysis to be a helpful adjunct. The use of a time-contingent "pain cocktail" as an oral medication was a useful strategy for 88% of respondents. The least labor-intensive modality reported was patient-controlled analgesia (PCA) for 84.5% of respondents; intravenous opiate fusion, 5.3%; and epidural analgesia, 11.2%. CONCLUSIONS: The survey describes caregiver concerns regarding this patient population, including medication use, sedation, length of hospital stay, and evaluation techniques.

Effect of patient position on the incidence of vasovagal response to venous cannulation.

BACKGROUND: This study was undertaken to determine the effect of patient position on the incidence of vasovagal responses to venous cannulation in ambulatory surgery patients. METHODS: Three hundred surgical outpatients, aged 18 to 40 years, were randomly assigned by week to the sitting or recumbent position. Blood pressure and heart rate were recorded during and for 6 minutes following venous cannulation. An observer recorded signs and symptoms suggestive of a vasovagal response. RESULTS: A vasovagal reaction occurred in 12.6% of sitting patients and 2.1% of recumbent patients. Two sitting patients, 1.3%, experienced frank syncope. Symptomatic patients were more likely (39.1%) than asymptomatic patients (8.3%) to have a history of fainting. In symptomatic patients who were sitting, mean arterial pressure fell from 90.4 mm Hg (SD, 10.6) at baseline to 64.4 mm Hg (SD, 14.3) during cannulation. Similarly, heart rate fell from 76.6 beats per minute (SD, 15.6) at baseline to 59.0 beats per minute (SD, 11.7) after cannulation. CONCLUSIONS: The vasovagal response during venous cannulation occurs more frequently in the sitting patient who has a history of fainting and is associated with a significant decline in blood pressure and heart rate.

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.

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.

Postoperative pain management in gynecology 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).