Minor complications following ambulatory surgery — such as post-operative pain, nausea, vomiting and bleeding — occur at predictable rates. For example, vomiting occurs in 10 to 20 percent of patients, nausea in 10 to 40 percent and incisional pain in 30 percent.1 Those are expected, and most can be treated with traditional therapies, including the use of anti-emetic drugs, analgesics such as acetaminophen, non-steroidal anti-inflammatory agents or narcotics and ice applied to the surgical site.
However, there are patients who experience more severe complications, such as the 11 percent whose severe pain will not subside. 2 Other patients may experience severe nausea and vomiting or excessive bleeding, which, combined with pain, account for the majority of post-ambulatory surgery hospital admissions. Other complications that can result in hospital admission include cardiac or respiratory issues, which are less frequent but still serious.
While there will always be small incidences of post-operative complications, many can be avoided with a few essential procedures and policies. These tips will help reduce the outpatient surgical center's post-operative hospital admission rate and also result in higher patient satisfaction.
Pre-Screen patients preoperatively
The number one strategy to avoid post-operative complications is patient selection. All patients need to be screened prior to the day of surgery to determine if outpatient surgery is the right choice for them. Patients with pre-existing comorbidities such as heart disease, lung disease, obesity or the presence of obstructive sleep apnea, in particular, must be carefully evaluated to ensure they are stable enough to undergo ambulatory surgery.
A thorough pre-operative evaluation of patients before they arrive in the center is critical to identify those patients with conditions that would make them more susceptible to post-operative complications. Most patients can be screened over the phone or online, but high-risk patients should be evaluated by the anesthesiologist to ensure they are acceptable candidates for an outpatient setting. If the physician determines the patient is not a good candidate for an ambulatory surgical center due to pre-existing conditions, the surgery can be rescheduled at a hospital where the patient can be monitored and admitted overnight for observation or further treatment.
Most patients do not have obvious medical histories that would preclude them from receiving care in an outpatient surgery center. However, all patients should be evaluated to determine their risks for developing post-operative complications. For example, nonsmokers, patients with a history of motion sickness and females — especially those undergoing gynecological procedures — are more likely to develop post-operative nausea and vomiting. These patients should be identified pre-operatively so that appropriate therapy can be given to try to avoid this uncomfortable complication.
Certain procedures are also more likely to result in post-operative bleeding. Large bladder tumors and many prostate procedures fall into this category. Careful pre-operative screening by the surgeons will determine which patients might benefit from having their surgery performed in a hospital.
Similarly, some procedures are more likely than others to cause significant post-operative pain. Orthopedic procedures and inguinal hernia repairs fall into this category. For patients undergoing painful procedures, a multimodal approach to analgesia is necessary. This includes using narcotics, non-steroidal anti-inflammatory agents and peripheral nerve blocks. Other drugs commonly used in a multimodal approach include acetaminophen, gabapentin and ketamine, among others. Because these drugs work at different points of the pain pathways, the end result is a synergistic effect that decreases the severity of post-operative pain. The multimodal analgesic approach works particularly well in orthopedic cases, as peripheral nerve blocks are very effective in relieving pain for 12 to 24 hours after surgery.
Communicate with patients, surgeons, and anesthesiologists
The key to avoiding post-operative complications comes down to communication between everyone involved. Part of that is pre-screening, but another critical component is patient education and communication. Patients taking pre-operative anticoagulant medications such as aspirin, warfarin or NSAIDs, as well as other medications that could cause complications, need to know to stop taking those medications at the appropriate time prior to surgery. This can also include vitamins or dietary supplements, not just OTC and prescription drugs, which is why it's important to ask patients about everything they take.
Communication between surgeons and anesthesiologists is also key. Both need to share information about the patient and collaborate on the best course of treatment before, during and after surgery. The more they're able to share, the better prepared all parties will be to prevent complications.
Work with best practices
Regardless of which anesthesia provider you choose, its anesthesiologists should all be qualified and adhere to standards set forth by the American Society of Anesthesiologists. These guidelines include the following: the facility having the appropriate equipment and enough staffing; the anesthesiologist assigned to the patient performing pre-operative assessments; a documented anesthesia plan developed by an anesthesiologist and discussed and accepted by the patient; and anesthetics administered by anesthesiologists or by qualified medical personnel under the direction of an anesthesiologist. 3 As discussed earlier, the provider should be involved in pre-operative screening to ensure treatment in an outpatient setting is appropriate.
Send high-risk patients to the hospital for surgery
It may not be a popular decision, but high-risk patients and patients whose pre-screenings raise red flags are better off having their procedures performed in a hospital setting, rather than being transferred to the hospital after surgery due to complications. Most surgeons would rather not transfer patients from the surgery center to the hospital and appreciate when the center and anesthesiologists work collaboratively to assess patients and determine which cases are better suited for the hospital. The surgery center also benefits by sending high-risk patients to the hospital by stopping complications from occurring in the center. For the patient, safety comes before anything else. It's better to lose a high-risk case than to end up with serious postoperative complications.
Dr. Steven Sheinman, MD, is chairman of anesthesia, medical director at North Miami Beach Surgical Center and national medical director of ambulatory anesthesia, as well as Miami-Dade County regional medical director for Sheridan Healthcorp Inc. After receiving his medical degree from the State University of New York at Stony Brook and completing his internship in internal medicine at the Beth Israel Medical Center, Dr. Sheinman completed his anesthesiology residency at the Columbia Presbyterian Medical Center in New York City.
1. Press, Christopher D., MD (2013, September 10). General anesthesia [article]. Retrieved from http://emedicine.medscape.com/article/1271543-overview
2. Jenkins, K. and Baker, A. B. (2003), Consent and anaesthetic risk. Anaesthesia, 58: 962–984. doi: 10.1046/j.1365-2044.2003.03410.x Retrieved from http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2003.03410.x/full
3. American Society of Anesthesiologists. (n.d.) Standards, Guidelines, Statements and Other Documents. Retrieved from http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx
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