Pendahuluan
Salah satu perubahan paling penting
dalam praktek bedah : rawat inap
rawat jalan.
USA : bedah rawat jalan 70% dari
seluruh operasi terencana (elektif).
Inggris: 34% pada tahun 1989 menjadi
49% pada tahun 2001 , 2002.
Keuntungan bedah rawat jalan: biaya
lebih murah, menguntungkan untuk
pasien dan keluarganya.
McGrath B, Chung F. Anesth Clin of North
America, June 2003; 21(2)
Definisi Pemulihan
Pemulihan segera : saat pasien
bangun dari anestesi.
Pemulihan Intermediet: bila
pasien mencapai kriteria untuk
dipulangkan
Pemulihan Jangka Panjang: bila
pasien kembali ke keadaan fisiologis
seperti sebelum di operasi.
McGrath B, Chung F. Anesth Clin of North America, June 2003;
21(2)
Fast tracking
SAFE
Advent of rapid and short acting drugs for
induction and maintenance of anesthesia
(Propofol, Sevoflurane, Desflurane,
remifentanyl).
Patient can achieve Aldrete score 9 or 10
upon arriving in the PACU.
Fast tracking refers to ability to transfer
directly from OR to Phase II recovery area.
Discharge
A successful ambulatory surgical program
depends on the appropriate and time
discharge of patient after anesthesia.
Using PADSS : base on vital sign
(BP,HR,RR, temp), ambulation,
nausea/vomiting, pain, surgical bleeding.
Recovery Phase I : Modified Aldrete Score.
Phase II Recovery: PADSS
AFTER
GUIDE
LINES
Postoperative pain
Main criteria performing ambulatory
surgery is minimal postoperative pain,
and can be controlled with oral
analgesia.
Pain is still a common reason for delay
in discharge, for contact with the family
doctor, for unanticipated hospital
admissions.
Important to understand the pattern of
pain and define predictive factor for
severe pain (orthopedic, duration of
surgery : >90 minutes 10% severe pain,
Dose
Route
Fentanyl
Meperidine
Morphine
Acetaminophe
n
Codeine
Ketorolac
1,0-2,0 ug/kg
0,5-1 mg/kg
0,05-1,0 mg/kg
60 mg/year or 25-40
mg/kg
0,5-1 mg/kg
30-60 mg (0,5-1
mg/kg)
Iv
Im
Iv/im
Po/pr
Po
Im/iv
PONV
Remain problem after ambulatory surgery.
Avoid using N2O, Prostigmine.
20-30% after GA, 35% of patients after
discharge home.
Antiemetic with droperidol 0,625-1,25 mg
iv, droperidol 0,625 + metoclopramide 10
mg iv, ondansetron 4-8 mg iv,
dexamethasone 8 mg iv.
Twersky RS. ASA Annual Meeting, 2002
ISO
HAL
DES
PROP
6-74
(2-20)
33-69
(8-33)
6-20
(8-13)
20-38
12-20
(0-7)
Patient education
Patient have a responsible individual
to accompany at home after
discharge (reduce adverse
outcomes, increase patient comfort
and satisfaction).
Provided written instruction (diet,
medications, activities, phone
number).
Not consume alcohol, drive vehicles,
make important decisions for 24
hours.
Treatment recommendation
Summary
Formulating an ambulatory
anesthesia plan that balances drugs
effectiveness, side effect profile,
patients preference, and associated
reduction of total cost.
Patient arrive for ambulatory surgery
anesthesia with the mistaken
perception that the experience will
be no more difficult than walk in the
park
References
Practice Guidelines for Postanesthetic
Care. Anesthesiology, March 2002;96(3).
Twersky R. Recovery and Discharge of the
Ambulatory Anesthesia Patient. ASA
Annual Meeting, Oct 2002.
McGrath B, Chung F. Postoperative
recovery and discharge. Anesth Clin of
North America, June 2003; 21(2)