ISAKanyakumari - Anaesthesia Practice in Kanyakumari District

ANAESTHESIA PEARLS

Post Partum Haemorrhage - Anaesthetists
Hypotensive Patients
Recovery

Post Partum Haemorrhage - Anaesthetists

What Anaesthetists should know about Post Partum Haemorrhage

Role of Anaesthetist in the management of PPH

Whenever the Obstetrician lands up in unexpected PPH, they become nervous and delay the decision making and rely the next immediately available expert, the Anaesthetist for the management of PPH mainly in rural areas. So, the Anaesthetists must have a sound knowledge about the recent concepts in the management of PPH.

This article explain the multimodal approach of management of PPH based on the “PREVENTION AND MANAGEMENT OF POSTPARTUM HAEMORRHAGE” Green-top Guideline No. 52, of Royal College of Obstetricians and Gynaecologists.

Definition of postpartum haemorrhage

Primary PPH involving an estimated blood loss of 500–1000 ml (and in the absence of clinical signs of shock) should prompt basic measures (close monitoring, intravenous access, full blood count, group and screen) to facilitate resuscitation should it become necessary.

If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml (or has clinical signs of shock or tachycardia associated with a smaller estimated loss), this should prompt a full protocol of measures to achieve resuscitation and haemostasis.

Prediction and prevention of postpartum haemorrhage

	Most cases of PPH have no identifiable risk factors.
	Active management of the third stage of labour lowers maternal blood loss and reduces the risk of PPH.
	Prophylactic oxytocics should be offered routinely in the management of the third stage of labour in all women as they reduce the risk of PPH by about 60%.
	For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour.

	For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss.
	A bolus dose of oxytocin may possibly be inappropriate in some women, such as those with major cardiovascular disorders, suggesting that a low-dose infusion might be a safer alternative.
	Syntometrine (® Alliance) may be used in the absence of hypertension (for instance, antenatal low haemoglobin) as it reduces the risk of minor PPH (500-1000 ml) but increases vomiting.

	Misoprostol is not as effective as oxytocin but it may be used when the latter is not available, such as the home-birth setting.
	All women who have had a previous caesarean section must have their placental site determined by ultrasound. Where facilities exist, magnetic resonance imaging (MRI)may be a useful tool and assist in determining whether the placenta is accreta or percreta.
	Women with placenta accreta/percreta are at very high risk of major PPH. If placenta accreta or percreta is diagnosed antenatally, there should be consultant-led multidisciplinary planning for delivery.
	Consultant obstetric and anaesthetic staff should be present, prompt availability of blood, fresh frozen plasma and platelets be confirmed and the timing and location for delivery chosen to facilitate consultant presence and access to intensive care.
	Available evidence on prophylactic occlusion or embolisation of pelvic arteries in the management of women with placenta accreta is equivocal. The outcomes of prophylactic arterial occlusion require further evaluation.

How should PPH be managed?

Once PPH has been identified, management involves four components, all of which must be undertaken SIMULTANEOUSLY: communication, resuscitation, monitoring and investigation, arresting the bleeding.

Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock):

	Intravenous access (14-gauge cannula x 1).
	Commence crystalloid infusion.

Full protocol for MAJOR PPH (blood loss > 1000 ml and continuing to bleed OR clinical shock):

	Assess airway.
	Assess breathing.
	Evaluate circulation
	Oxygen by mask at 10–15 litres/minute.
	Intravenous access (14-gauge cannula x 2, orange cannulae).
	Position flat.
	Keeps the woman warm using appropriate available measures;
	Transfuse blood as soon as possible.
	Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann’s solution (2 litres) and/or colloid (1–2 litres) as rapidly as required.
	The best equipment available should be used to achieve RAPID WARMED infusion of fluids.
	Special blood filters should NOT be used, as they slow infusions.
	Recombinant factor VIIa therapy should be based on the results of coagulation.

Fluid therapy and blood product transfusion

Crystalloid :	Up to 2 litres Hartmann’s solution
Colloid arrives:	Up to 1–2 litres colloid until blood
Blood:	Crossmatched
	If crossmatched blood is still unavailable, give uncrossmatched group-specific blood OR give ‘O RhD negative’ blood

Fresh frozen plasma:	4 units for every 6 units of red cells or prothrombin time /activated partial thromboplastin time > 1.5 x normal (12–15ml/kg or total 1litres)
Platelets concentrates:	If PLT count < 50 x 109
Cryoprecipitate:	If fibrinogen < 1 g/l

A 2006 guideline from the British Committee for Standards in Haematology summarises the main therapeutic goals of management of massive blood loss is to maintain:

	haemoglobin > 8g/dl
	platelet count > 75 x 109/l
	prothrombin < 1.5 x mean control
	activated prothrombin times < 1.5 x mean control
	fibrinogen > 1.0 g/l

What investigations should be performed and how should the woman be monitored?

Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock and bleeding ceasing):

Consider venepuncture (20 ml) for:

	group and screen
	full blood count
	coagulation screen including fibrinogen
	pulse and blood pressure recording every 15 minutes.

Full Protocol for MAJOR PPH (blood loss greater than 1000ml and continuing to bleed OR clinical shock):

	Consider venepuncture (20 ml) for:
	Crossmatch (4 units minimum)
		Full blood count
		Coagulation screen including fibrinogen
		Renal and liver function for baseline.
		Monitor temperature every 15 minutes.
		Continuous pulse, blood pressure recording and respiratory rate (using oximeter, electrocardiogram and automated blood pressure recording).
		Foley catheter to monitor urine output.
		Two peripheral cannulae, 14- or 16-gauge.
		Consider arterial line monitoring (once appropriately experienced staff available for insertion).
		Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high Dependency unit on delivery suite, if appropriate.
		Recording of parameters on a flow chart such as the modified obstetric early warning system charts.
		Documentation of fluid balance, blood, blood products and procedures.

Anaesthetic management

The anaesthetist needs to able to assess the woman quickly, to initiate or continue resuscitation to restore intravascular volume and provide adequate anaesthesia.

The presence of cardiovascular instability is a relative contraindication to regional anaesthesia. Blockage of the sympathetic system can potentially lead to worsening hypotension due to haemorrhage. If cardiovascular stability has been achieved and there is no evidence of coagulation failure, regional anaesthesia can be used. This may be particularly appropriate where a working epidural has been in place during labour. Continuous epidural block is preferred over spinal, as it allows better blood pressure control and for prolonged surgery.

When there is continuing bleeding and the cardiovascular stability is compromised, general anaesthesia is more appropriate. Rapid sequence induction is the gold standard to reduce the risk of aspiration. Cardiostable induction agents with minimal peripheral vasodilators should be considered and adrenaline and atropine being available during induction. Ventilation with high oxygen concentrations may be needed until the bleeding is under control.

Arresting the bleeding

Causes for PPH may be considered to relate to one or more of ‘the four Ts’:

	tone (abnormalities of uterine contraction)
	tissue (retained products of conception)
	trauma (of the genital tract)
	thrombin (abnormalities of coagulation)

The most common cause of primary PPH is uterine atony. However, clinical examination must be undertaken to exclude other or additional causes:

	retained products (placenta, membranes, clots)
	vaginal/cervical lacerations or haematoma
	ruptured uterus
	broad ligament haematoma
	extragenital bleeding (for example, subcapsular liver rupture)
	uterine inversion

When uterine atony is perceived to be a cause of the bleeding, the following mechanical and pharmacological measures should be instituted, in turn, until the bleeding stops:

	Bimanual uterine compression (rubbing up the fundus) to stimulate contractions
	Ensure bladder is empty (Foley catheter, leave in place).
	Syntocinon 5 units by slow intravenous injection (may have repeat dose).
	Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension)
	Syntocinon infusion (40 units in 500ml Hartmann’s solution at 125ml/hour) unless fluid restriction is necessary
	Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma)
	Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use
	Misoprostol 1000 micrograms rectally

If pharmacological measures fails to control the haemorrhage, initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate firstline ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available expertise:

	balloon tamponade
	haemostatic brace suturing (such as using procedures described by B-Lynch or modified compression sutures)
	bilateral ligation of uterine arteries
	bilateral ligation of internal iliac (hypogastric) arteries
	selective arterial embolisation.
	If tracheal intubation is not considered to be indicated but there is some (small) increase or concerns about regurgitation risk a second generation supraglottic airway is a more logical choice than a first generation one.
	Where aspiration has been recognised as a risk at induction, steps should be taken to reduce the risk of aspiration at emergence.
	Anaesthetists caring for patients undergoing intra-oral surgery should be educated in the prevention, detection and management of blood clot aspiration.

It is recommended that a laminated diagram of the brace technique be kept in theatre.

Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture).

A second consultant clinician should be involved in the decision for hysterectomy.

Informed consent for hysterectomy should be obtained.

Ref:

1. Postpartum Haemorrhage, Prevention and Management (Green-top 52)

2. PPH Management: The Anesthesiologist's Perspective from Larry Chu

Hypotensive Patients

Rapid sequence induction in shocked or hypotensive patients

OVERVIEW

	“Shock is an anaesthetic” so the basic rapid sequence intubation (RSI) is “roc/sux-tube-apology” in a shocked patient
	Use judicious doses of sedatives to make the procedure as non-distressing as possible, without compromising safety
	Remember that primary objective is to keep the patient alive while achieving intubation!

PERI-INTUBATION HYPOTENSION

Importance

	Peri-intubation hypotension is associated with increased mortality
	The most important risk factors for death and complications prior to intubation (Schwartz et al 1995) are:
		haemodynamic instability
		requirement for pressor agents

Mechanisms

	underlying disease
	inadequate resuscitation
	cardiodepressant effects of induction agents
	decreased venous return due to positive pressure ventilation
	haemodynamic effects of worsening acidosis during apnoea

Actions

	adequately fluid resuscitate prior to, and during, RSI
	consider using a pressor agent (e.g. adrenaline) prior to intubation to prop up blood pressure before the administration of an induction agent
	choose an induction agent and a dose that is least likely to exacerbate hypotension (e.g. ketamine)
	avoid high tidal volumes and dynamic hyperinflation when ventilating, which exacerbates hypotension by decreasing venous return and cardiac output

CHOICE AND DOSES OF AGENTS

Induction agent

	the dose of any induction agent used is more important than the choice of the agent — use lower doses than usual, regardless of the agent used
	ketamine is the induction agent of choice in the shock patient (see below)
	many intensivists use fentanyl and midazolam in low doses as their mainstays for the induction of shocked patients; however onset is very slow in shocked patient (e.g. up to or greater than 5 minutes)
	even propofol and thiopentone can be used in the shocked patient, but as little as 10% of the usual dose may be all that is needed — higher doses may lead to haemodynamic compromise (aka ‘propofol assassination’)/td>
	etomidate is not available in Australia, and may be best avoided due to ongoing concerns:
		it causes adrenal suppression which may be linked to increased mortality in septic patients (though many argue that etomidate is safe)
		it is unreliable as an induction agent in reduced doses (even in shocked patients)

Neuromuscular blockers

	dose higher, as onset for any given dose will be slower
	e.g. suxamethonium 2mg/kg or rocuronium 1.6 mg/kg IV

METABOLIC ACIDOSIS

	The compounding effect of uncorrected respiratory acidosis from apnea (regardless of the agents used) may be lethal
	During apnea from RSI, supported ventilation may be necessary in patients with profound metabolic acidosis

KETAMINE

	Ketamine is the least cardio-depressant induction agent available
	Ketamine usually exhibits a stimulatory effect on the cardiovascular system: the mechanism is poorly understood but probably involves a centrally mediated sympathetic response and inhibition of noradrenaline reuptake
	In the severely shocked patient beware of catecholamine depletion or resistance to further catecholamine effect: the direct effects of ketamine on myocardial depression may outweigh the indirect sympathetic effects and haemodynamic collapse may still occur (this is only likely to occur at high doses)
	Consider doses as low as 0.25 to 0.5mg/kg IV, rather than the usual 1-2 mg/kg IV, for RSI of the shock patient
	Rapid administration of ketamine alone can render the patient apneic: in the RSI setting, apnea will occur anyway from the administration of paralytics (see the comments above), but has important implications when ketamine is used in other settings such as procedural sedation or delayed sequence intubation (DSI)

How to Intubate a Patient with Hypotension

Podcast

Literature

Best Review Article

Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?
Anaesthesia 2009;64:532

Hypotension in the peri-intubation is bad and is a source of mortality

Hemodynamically unstable or on pressors prior to intubation is the biggest factor assoc. with death and complications. (Schwartz et al. Anesthesiology 1995;82:367)and (Heffner et al. J Crit Care 2012 Aug;27(4):417)

Etomidate

Etomidate is probably safe in moderately shocked patients (Acad Emerg Med 2006;13:378)

Etomidate can definitely drop Blood Pressure (Crit Care 2012;16:R224)

Ketamine

Ketamine given to patients with horrible ejection fractions (Thangathurai et al.; Anesth 1988;69(3a):A79) , in OR anesthetized pts (Prakt Anaesth. 1976 Dec;11(6):397-404)and In-Vitro human-tissue studies show Ketamine to be least cardio-depressant (Anesthesiology 1996;84:397). Another anesthesia study showed no drop from initial values after large and repeated doses (Br J Anaesth 1976;48:1071)

Best study, reasonable doses (CCM 1983;11(9):730) showed excellent stability

A further anesthesia study (Anesth and Analg 1980;58(5):355) 1/12 patients dropped HR with no effect on CI.

Case report of 2 arrests post-ketamine (J Inten Care Med 2012; Dewhirst et al.)

Ketamine in ICP (Emerg med australia 2006;18(1):37-44)

Two RCTs of etomidate vs. ketamine showed both are equally hemodynamically stable, but this was full dose ketamine (Am J Emerg Med 2013;31:1124 and Lancet. 2009 Jul 25;374(9686):293-300). Middle dose may be even better.

Paralytics

Anesth Analg. 2000 Jan;90(1):175-9.

Ambulatory Anaesthesia and Surgery

Recovery Characteristics after Ambulatory Anaesthesia and Surgery

Mohamed Ezzat Moemen

Recovery:

Recovery is a frequently used term in anaesthetic and surgical practice. This term may be perceived very differently among patients, surgeons and anaesthetists .

Patients consider that recovery ensues when they are able to resume their previous life-style.

Surgeons consider that their patients have recovered when surgical sutures are removed or when their patients are discharged from the hospital. The variable most often used by surgeons to assess recovery is the duration of patient hospital stay.

Anaesthetists think that their patients have recovered when they regain their consciousness and preoperative physiological and psychological states.

Anaesthetists deal with recovery as a continual process, the early stage of which overlaps the end of intraoperative care. The recovery process may last many days and can be divided into three distinct phases.

Early (phase I) recovery lasts from discontinuation of anaesthesia until patients awaken and regain their vital protective reflexes and motor functions.

Intermediate (phase II) recovery denotes immediate clinical recovery as coordination and ambulation allowing home-readiness.

Patients are then discharged home to complete full recovery including its psychological component, a stage termed late (phase III) recovery.

Early (Phase I) recovery:

Early (phase I) recovery takes place in the postanaesthesia care unit (PACU) under the care of trained nurses until patients have recovered enough to allow their safe transfer to an ambulatory surgical unit (ASU) or to another secondary step-down phase II recovery area. This is usually achieved by using the Aldrete and Kroulik or the modified Aldrete scoring system . Recently, the Bispectral Index (BIS) is evolving as a useful indicator of patient wakefulness in the operating room (OR) and the PACU to be transferred to step-down phase II recovery area.

The Aldrete scoring system:

The Aldrete and Kroulik scoring system was first described in 1970. This system assigns a score of 0-2 to activity, respiration, circulation, consciousness and colour, giving a maximum score of 10 (table 1). A score of ≥ 9 indicates sufficient patient recovery for transference from the PACU to the phase II recovery area. Although not originally designed for ambulatory surgical patients, this scoring system is still used in many PACU’s.

Table (1): The standard Aldrete scoring system (5)

	Points
Activity
Able to move 4 extremities	2
Able to move 2 extremities	1
Able to move 0 extremities	0
Respiratory
Able to deep breath and cough freely	2
Dyspnea, shallow or limited breathing	1
Apneic	0
Circulation
Preoperative BP ± 20 mmHg of preanaesthetic level	2
Preoperative BP ± 21 to 49 mmHg of preanaesthetic level	1
Preoperative BP ± 50 mmHg of preanaesthetic level	0
Consciousness
Fully awake	2
Arousal on calling	1
Not responding	0
Colour
Normal	2
Pale, dusky, blochy	1
Cyanotic	0
Total score	10

The modified Aldrete scoring system:

With the advent of pulse oximetry as a more reliable indicator of oxygenation than clinical observation, a modified Aldrete scoring system has been designed (table 2) . In this modified system, the colour parameter of the original system is replaced by an oxygen or room-air saturation parameter. Again, the maximum score is 10 and a score of ≥9 indicates sufficient patient recovery for transference form the PACU to phase II recovery area.

Table (2): The modified Aldrete scoring system

	Points
Activity
Able to move 4 extremities	2
Able to move 2 extremities	1
Able to move 0 extremities	0
Respiratory
Able to deep breath and cough freely	2
Dyspnea, shallow or limited breathing	1
Apneic	0
Circulation
Preoperative BP ± 20 mmHg of preanaesthetic level	2
Preoperative BP ± 21 to 49 mmHg of preanaesthetic level	1
Preoperative BP ± 50 mmHg of preanaesthetic level	0
Consciousness
Fully awake	2
Arousal on calling	1
Not responding	0
Oxygen saturation
Able to maintain oxygen saturation > 92% on room air	2
Needs oxygen inhalation to maintain oxygen saturation > 90%	1
Oxygen saturation < 90% even with oxygen supplementation	0
Total score	10

The Bispectral Index:

The Bispectral Index (BIS) is a multivariate index derived from the spontaneous electroencephalogram (EEG) (10). It uses a processed EEG to monitor anaesthetic depth . The electrodes or the sensors of this monitor are attached to three circles on the patient. The first is a forehead contact 4cm above the nose. The second is a contact above the right or left orbit. The third is a contact on the temple between the hair-line and the outer angle of the orbit.

The BIS determines a linear and a non-linear component. It uses a space lab monitor for a numeric zone and moving wave-form updated every two seconds. It produces a unitless score of zero to 100, where 100 means that the patient is awake and responsive, 70 means that free recall is lost and 60 means that consciousness is lost. Below a BIS value of 60, there is a very low probability of patient recall. The range between 60 and 50 may denote deep sedation or light anaesthesia, and below 50, the patient is usually unconscious .

The use of BIS has been shown to allow more accurate titration and more economic utilization of anaesthetic agents , to reduce time to wakefulness and extubation and to promote faster theatre turnaround. Intraoperative BIS monitoring could produce significant improvements in patient orientation on arrival at PACU and time to discharge eligibility. A recent large prospective study compared the recovery characteristics of 50-40 range BIS monitored ambulatory surgical patients with controls using the modified Aldrete score .

On arrival to the PACU, the study group patients had better ventilatery functions, more stable haemodynamics and they were more awake and active. So, they had higher modified Aldrete scores, which produced safer and shorter PACU stay with better recovery characteristics contributing to patient transfer to the step-down phase II recovery area. It can be concluded that a postoperative BIS score more than 70 allows patient transfer to the PACU or even his fast-tracking to the ASU.

The fast-tracking scoring system

Newer anaesthetics and techniques may allow more rapid awakening and phase I early recovery may be completed in the OR. Then, patients are transferred directly to the ASU, bypassing the PACU, a process known as fast-tracking .

Table (3): Criteria for fast-tracking after outpatient anaesthesia (19)

	Points
Level of consciousness
Awake and oriented	2
Arousable with minimal stimulation	1
Responsive only to tactile stimulation	0
Physical activity
Able to move all extremities on command	2
Some weakness in movement of extremities	1
Unable to voluntarily move extremities	0
Haemodynamic stability
BP < 15% of baseline MAP value	2
BP 15-30% of baseline MAP value	1
BP > 30% of baseline MAP value	0
Respiratory stability
Able to breath deeply	2
Tachypnea with good cough	1
Dyspneic with weak cough	0
Oxygen saturation status
Maintains value > 90% on room air	2
Requires supplemental oxygen (nasal prongs)	1
Saturation < 90% with supplemental oxygen	0
Postoperative pain assessment
Non or mild discomfort	2
Moderate to severe pain controlled with iv analgesics	1
Persistent severe pain	0
Postoperative emetic symptoms
Maintains value > 90% on room air	2
Transient vomiting or retching	1
Persistent moderate to severe nausea and vomiting	0
Total score	14

MAP = mean arterial pressure

The proposed fast-tracking scoring system takes in consideration pain and emetic symptoms, added to the modified Aldrete five parameters completing 14 scoring points. A minimal score of 12 (with no score < 1 in any individual category) would be required for a patient to bypass the PACU after ambulatory general anaesthesia and surgery.

Clinical guidelines:

Wetchler suggested clinical guidelines for safe patient discharge after ambulatory surgery (table 4).

Table (4): Wetchler’s guidelines for safe patient discharge after ambulatory surgery

	Vital silgns stabe: these include temperature, pulse, respiration and blood pressure when appropriate. Vital signs should remain stable for a period of not less than half an hour and be consistent with patient’s age and preanaesthesia levels.
	Ability to swallow and cough: the patient must demonstrate the ability to swallow fluids and be able to cough.
	Ability to walk: the patient demonstrates ability to perform movement consistent with age and developmental level (sit, stand, and walk).
	Minimal nausea, vomiting and dizziness:
		Minimal nausea: absence of nausea, or if nausea is present, the patient can still swallow and retain some fluids.
		Minimal vomiting: vomiting is either absent or, if present, does not require treatment. Following vomiting that requires treatment, the patient should be able to swallow and retain fluids.
		Minimal dizziness: dizziness is either absent or present only upon sitting and the patient is still able to perform movement consistent with age.
	Absence of respiratory distress: the patient exhibits no signs of snoring, obstructed respiration, stridor, retractions, or croupy cough.
	Alert and oriented: the patient is aware of surroundings and what has taken place and is interested in returning home.

Again, Kortilla summarized widely accepted clinical criteria for safe discharge after ambulatory surgery (table 5).

Table (5): Kortilla’s guidelines for safe patient discharge after ambulatory surgery

	Vital signs must have been stable for at least one hour
	The patient must be:
		Oriented to person, place and time
		Able to retain orally administered fluids
		Able to void
		Able to dress
		Able to walk without assistance
	The patient must not have
		More nausea and vomiting.
		Excessive pain.
		Bleeding.
	The patient must be discharged by both the person who administered anaesthesia and the person who performed surgery, or by their designates. Written instructions for the postoperative period at home, including a contact place and person, must be reinforced.
	The patient must have a responsible, “vested” adult escort them home and stay with them at home.

Clinical criteria:

The postanaesthesia discharge scoring system (PADSS)

Apart from psychomotor tests and clinical guidelines, Chung (1993) designed his early version of postanaesthesia discharge scoring system (PADSS) including 10 points and patients with scores of ≥9 are considered fit for home discharge (table 6) . In this way patient discharge is addressed in a simple, clear and reproducible manner to meet national medical standards. Nurses are able to evaluate the postoperative course of the patient in a systematic way.

Table (6): Postanaesthesia discharge scoring system (PADSS)

	Points
Vital signs
Within 20% of preoperative value	2
20% - 40% of preoperative value	1
< 40% of preoperative value	0
Activity, mental status
Oriented and steady gait	2
Oriented or steady gait	1
Neither	0
Pain, nausea, vomiting
Minimal	2
Moderate	1
Severe	0
Surgical bleeding
Minimal	2
Moderate	1
Severe	0
Intake, output
Has had postoperative fluids and voided	2
Has had postoperative fluids or voided	1
Neither	0
Total score	10

The modified postanaesthesia discharge scoring system (MPADSS):

Removing the requirements to drink and to void (elimination of input and output), and separating the PONV and pain elements, Chung et al has modified the early version of the PADSS into the modified postanaesthesia discharge scoring system (MPADSS) , which was extensively used at the Toronto Hospital for determining home-readiness. The MPADSS is based on five criteria: vital signs, ambulation, PONV, pain and surgical bleeding (table 7). Each of these items is assessed independently and assigned a numerical score of 0-2, with a maximal score of 10. Patients are fit for discharge when their score is ≥9. Patients should be able to stand and take few steps or to sit upright if the surgical procedure does not permit standing. Delays in discharge are related to persistent symptoms such as pain, PONV, hypotension, dizziness, unsteady gait, syncope, asthma or unavailable accompanying care-given . The MPADSS is a simple way to establish a routine of repeated re-evaluation which may result in improved patient supervision.

Table (7): the modified postanaesthesia discharge scoring system (MPADSS)

	Points
Vital signs
Vital signs must be stable and consistent with age and preoperative baseline
BP and pulse within 20% of preoperative baseline	2
BP and pulse within 20%-40% of preoperative baseline	1
BP and pulse > 40% of preoperative baseline	0
Activity level
Patient must be able to ambulate at preoperative level
Steady gait, no dizziness, or meets preoperative level	2
Requires assistance	1
Unable to ambulate	0
Nausea and vomiting
Patient should have minimal nausea and vomiting before discharge
Minimal: successfully treated with PO medication	2
Moderate: successfully treated with IM medication	1
Severe : continues after repeated treatment	0
Pain
Patient should have minimal or no pain before discharge. The level of pain should be accepted to the patient. Pain should be controllable by oral analgesics. The location, type, and intensity of pain should be consistent with anticipated postoperative discomfort.
Acceptability:
Yes	2
No	1
Surgical bleeding
Postoperative bleeding should be consistent with expected blood loss for the procedure.
Minimal: does not require dressing change	2
Moderate: up to two dressing changes required	1
Severe: three or more dressing changes required	0
Total score	10

BP = blood pressure, PO = per orum, IM = intramuscular

Table (8): The modified Bomage Scale for motor block

• = full movement
1 = loss of hip flexion.
2 = loss of knee extension
3 = loss of planter flexion/ extension

One factor limiting the popularity of spinal anaesthesia for ambulatory surgery is postdural puncture headache (PDPH). However, it has been recently documented that needles of gauge ≥ 25 produce an incidence of PDPH of < 1% and that the reported headaches are mild and self-limited.

Table (9): Postoperative instructions for outpatients following ambulatory surgery procedures.

Activities postsurgery: Rest today

You may experience some dizziness or drowsiness following surgery procedure.
Do not consume alcohol, drive or make important personal or business decisions for 24h.

Activity level: see procedure specific instructions

Diet postsurgey:

Progress as tolerated without nausea and vomiting

Medications post surgery:

Medications taken prior to surgery should be resumed as ordered by your physician.
Mild aches, pains are not unusual and may be relieved by acetaminophen or similar non-aspirin pain medication postoperatively.
A prescription for other pain medication may be given by your doctor postoperatively. Take as instructed.

In an emergency: Call your doctor immediately for problems such as:

Bladder difficulties
Persistent nausea or vomiting
Bleeding that does not stop
Unusual pain
Fever
Redness/ swelling or drainage of pus

Call your doctor. If unable to contact your doctor, you may contact or go to the hospital emergency department.

Late (Phase III) recovery:

Recovery does not end once discharge criteria are met, because phase III recovery may take few days to be completed at home. Patients and their escorts are provided with written discharge instructions and information about emergency medical assistance if needed. It is a good practice to plan a follow-up telephone call from the ambulatory unit 24 hours after discharge to review postoperative progress and satisfaction (table 12). Additional contact with the patient is recommended if s/he has received spinal or epidural anaesthesia or if s/he has some additional difficulty postoperatively.

Table (10) Postoperative evaluation phone-call

Date and time or postoperative call ____/ ____ / _____
Problems since discharge:
1- Appetite / nausea	( ) Yes	( ) No
2- Vomiting	( ) Yes	( ) No
3- Score throat	( ) Yes	( ) No
4- Headache	( ) Yes	( ) No
5- Backache	( ) Yes	( ) No
6- Muscle ache	( ) Yes	( ) No
7- Pain at operative site	( ) Yes	( ) No
8- Temperature	( ) Yes	( ) No
9- Bleeding	( ) Yes	( ) No
10- Drowsiness	( ) Yes	( ) No
11- Pediatric patients: alterations in comfort / pain ______________________________
12- Other problems __________________________________________ _______________________________________________________
Physician follow-up required regarding problems found?	( ) Yes	( ) No

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It is important to mention that home-readiness after an outpatient surgery carried out under any anaesthetic technique does not coincide with street-fitness. Kortilla studied the effects of different analgesics, sedatives and anaesthetics on the psychomotor skills of volunteers and recommended that patients should refrain from driving for 24 and 48 hours if the duration of surgery was less than 30 minutes or equal to two hours respectively.

Ref:

Eg J Anaesth 2004 ,20 :449-57

ISA KANYAKUMARI

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