Fast-Tracking Concepts
Ambulatory anesthesia is administered with the dual goals of rapidly
and safely establishing satisfactory conditions for the performance of therapeutic
or diagnostic procedures while ensuring rapid, predictable recovery with minimal
postoperative sequelae. If careful titration of short-acting drugs permits safe
transfer of patients directly from the operating room suite to a less labor-intensive
recovery area, some patients can be discharged home within 1 hour after surgery,
thereby resulting in cost savings to the institution.[317]
[501]
[512]
Bypassing
the PACU has been termed "fast-tracking" after ambulatory surgery.[513]
In addition, fast-tracking can be accomplished directly from the PACU ("PACU fast-tracking")
by creating
TABLE 68-13 -- Criteria used to determine fast-track eligibility after ambulatory anesthesia
|
Criteria |
Score |
|
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 the extremities |
1 |
|
Unable to voluntarily move the extremities |
0 |
|
Hemodynamic Stability |
|
|
Blood pressure <15% of the baseline MAP value |
2 |
|
Blood pressure between 15% and 30% of the baseline MAP value |
1 |
|
Blood pressure >30% below the baseline MAP value |
0 |
|
Respiratory Stability |
|
|
Able to breathe 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 |
|
|
None or mild discomfort |
2 |
|
Moderate to severe pain controlled with IV analgesics |
1 |
|
Persistent severe pain |
0 |
|
Postoperative Emetic Symptoms |
|
|
None or mild nausea with no active vomiting |
2 |
|
Transient vomiting or retching |
1 |
|
Persistent moderate to severe nausea and vomiting |
0 |
|
Total score |
14 |
|
A score over 12 with no individual score less than 1 is required
for fast-tracking. |
|
MAP, mean arterial pressure. |
|
From White PF, Song D: New criteria for fast-tracking
after outpatient anesthesia: A comparison with the modified Aldrete's scoring system.
Anesth Analg 88:1069, 1999. |
a specialized area within an existing PACU where recovery procedures are organized
along the lines of a step-down unit.[514]
The criteria used to determine fast-track eligibility ( Table
68-13
) have been made even more stringent than the standard PACU discharge
criteria to reduce the need for nursing interventions in areas with less nursing
personnel.[515]
The use of anesthetic techniques
associated with more rapid recovery will result in fewer patients remaining deeply
sedated in the early postoperative period,[508]
[516]
decrease the risk for airway obstruction and
cardiorespiratory instability, and reduce the number of nursing interventions ( Table
68-14
and Table 68-15
).
[508]
[517]
By
using
anesthetic techniques associated with faster emergence from anesthesia, it should
be possible to reduce the need for "intensive" nursing care in the early postoperative
period.[518]
Therefore, a well-organized fast-tracking
program may permit an institution to use fewer nurses in the recovery areas and could
lead to significant cost savings. The fast-track concept is gaining wider acceptance
throughout the world.[519]
[520]
Fast-tracking children after ambulatory surgery is feasible and beneficial (e.g.,
shorter recovery time) when specific selection criteria are used.[506]
Even elderly outpatients can be fast-tracked after general anesthesia if short-acting
drugs are used.[516]
Most outpatients undergoing ambulatory surgery do not require
admission to a phase I recovery facility.[521]
Interestingly, bypassing the PACU after outpatient knee surgery was associated with
fewer unplanned hospital admissions.[522]
The primary
anesthetic-related cause of failure to fast-track after laparoscopic surgery was
residual sedation on emergence from anesthesia (propofol > sevoflurane > desflurane).
[508]
Other important reasons included residual
muscle weakness (because of nondepolarizing muscle relaxants) and surgical misadventures.
Unless side effects are minimized, bypassing the PACU will result in more nursing
interventions in the phase II recovery area.[522]
Improved titration of anesthetic drugs with the use of EEG-based
cerebral monitors (e.g., BIS, PSI, AEP, and spectral entropy) can lead to faster
emergence from general anesthesia[455]
[456]
and may prove useful in predicting the time required to achieve fast-track eligibility.
[523]
Furthermore, if outpatients are allowed to
recover by way of a fast-track pathway, the use of cerebral monitoring can actually
reduce discharge times.[524]
Whereas the availability
of more rapid and shorter-acting anesthetic drugs (e.g., propofol, sevoflurane, desflurane,
remifentanil) has clearly facilitated the early recovery process after general anesthesia,
the preemptive use of nonopioid analgesics (e.g., local anesthetics, ketamine, NSAIDs,
COX-2 inhibitors, acetaminophen)[127]
and antiemetics
(e.g., droperidol, metoclopramide, 5-HT3
antagonists, dexamethasone)[152]
will reduce postoperative side effects and accelerate both the immediate and late
recovery phases after ambulatory surgery. When compared with a conventional recovery
pathway, fast-tracked patients are eligible to be discharged home 30 to 90 minutes
earlier without compromising patient safety or satisfaction with their surgical experience.
[503]
The use of rapid- and short-acting general
anesthetics and opioid analgesics, as well as improved MAC and minidose spinal anesthetic
techniques, should allow virtually all outpatients to enjoy the benefits of "fast-track"
recovery.
 |
