小儿日间手术术后管理进展

小儿日间手术可最大限度地减少患儿与父母的分离,缓解患儿的焦虑情绪,降低医疗成本。然而,由于小儿特殊的解剖和生理学特点,麻醉术后易发生疼痛、恶心呕吐和谵妄等并发症。因此,术后管理是小儿日间手术顺利实施的重要环节之一,其规范化管理对于保障患儿安全,提高日间手术医疗质量起着至关重要的作用。本文就小儿日间手术术后常见并发症及出院标准相关研究进展进行综述。     

Updates in Pediatric Regional Anesthesia and Its Role in the Treatment of Acute Pain in the Ambulatory Setting

Purpose of Review

The purpose of this review is to summarize the latest advances in pediatric regional anesthesia with special emphasis on its role in the ambulatory surgical setting.

Recent Findings

Undertreated pain in children following ambulatory surgery is not a rare occurrence and it is associated with increased morbidity and significant psychosocial harm. Use of regional anesthesia as part of the anesthetic approach in the ambulatory setting is safe when performed on children under general anesthesia and inclusion of certain adjuncts improves block outcomes. Ultrasonographic visualization during blockade improves safety and prolongs duration. Ambulatory continuous nerve blocks in older children are safe, efficacious, and associated with high patient and caregiver satisfaction rates.

Summary

In the ever-growing field of pediatric same-day surgery, safe and efficient flow through the perioperative period necessitates use of a multimodal approach, of which regional anesthesia is but one important component. Perioperative complications are minimized with less opioid use, and yet appropriate pain management must be ensured. Pediatric regional anesthesia has been shown to be exceedingly safe under general anesthesia. Findings demonstrate that advances in ultrasound technology have contributed to safer and longer-lasting analgesia. It facilitates the development of new methods by which regional anesthesia can improve postoperative analgesia in children upon discharge and beyond.

     

Pharmacologic rationale for anesthetic agents in ambulatory practice

Patients undergoing surgery in the ambulatory setting require anesthetic agents that expedite postoperative recovery, minimize adverse side effects, and contribute to patient satisfaction. The newer anesthetic agents that are currently used in today's practice offer the flexibility needed to provide anesthesia care for a wide variety of diagnostic and therapeutic procedures performed on an outpatient basis. It is important for the perianesthesia nurse to be familiar with the anesthetic agents used in the operating room to fully understand the influence of these drugs on the patient's recovery process. The role of the perianesthesia nurse is vital in assessing the residual effects of the anesthetic agents and instituting proper nursing interventions during the patient's postanesthesia experience. This article focuses on the rationale for the use of a variety of anesthetic and related agents necessary for the provision of ambulatory anesthesia. The commonly used agents used in ambulatory anesthesia care and their influences on the continuum of care is reviewed.     

Postoperative Schmerztherapie nach ambulanten Operationen

Background

Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting.

Patients and methods

A total of 2,156?anaesthesiologists in private practice received a postal questionnaire which was limited to those anaesthesiologists who were responsible for postoperative pain therapy. The questionnaire included items such as types of surgery, techniques of anaesthesia and analgesic drugs used for pain management during the immediate postoperative phase and for the treatment at home as well as details of pain measurement.

Results

Out of 116?responses 108 could be analyzed covering a total of 86,616?patients receiving postoperative pain therapy, 80% of the operations were performed using general anaesthesia and local anaesthesia was additionally used in 9% of the institutions. In the perioperative period 66% of the respondents administered non-steroidal-antiinflammatory drugs (NSAIDs), 62% metamizol (dipyrone), 41% paracetamol (acetaminophen) and 73% opioids. After discharge 81% of the responding anaesthesiologists prescribed NSAIDs, 55% metamizol and 47% opioids for pain relief at home. Only 40% of the respondents measured and documented pain intensity. Nearly all respondents (93%) were satisfied with their pain management after outpatient surgery.

Conclusions

Pain therapy after ambulatory surgery significantly varied with respect to the methods, drugs and measures of quality assurance used by anaesthesiologists in private praxis. This survey demonstrated that the national guidelines of acute pain therapy have only been partially implemented.     

Ambulatory anesthesia and surgery in America: a historical background and recent innovations.

This article describes the history of ambulatory surgery and anesthesia in the United States. The innovations in surgical instrumentation and techniques, newer anesthesia drugs and techniques, as well as insurance provider changes that have led to an increase in the numbers and types of surgeries performed in outpatient settings in the United States, are detailed.     

Postoperative nausea and vomiting in outpatient surgery in younger children

The article deals with the problem of postoperative nausea and vomiting in ambulatory surgery in children. This complication is the most topical in children and can be dangerous in home, leading to serious consequences. The article considers the different causes of this complication, as well as the ways of prophylaxis and treatment. The aim of the study was the development of a differentiated approach to the antiemetic therapy in younger children in the outpatient setting. In the study participated 140 children aged from 1 to 5 years (ASA I-II), undergoing planned operations in the one-day surgery hospital. All children received antiemetic therapy: 65 children were receiving metoclopramide, 75 - ondansetron in the age dosages. At the second stage of the study was carried out feasibility assessment antiemetic therapy for children from 1 to 3 years. 20 children were receiving ondansetron, 20 - prevention has not been carried out. Analysis of the results showed that the frequency of nausea and vomiting in "ondansetron" group was in 4 times lower in comparison with metoclopramide. The frequency of postoperative nausea and vomiting occurrence in children aged 1 to 3 years significantly lower than in the age group of 3 to 5 years.     

Children's postoperative pain at home: family interview study

The purpose of this study was to: (i) describe the methods that are used in the identification and management of postoperative pain in children aged 1-7 years after minor outpatient surgery at home; (ii) to identify parents' perceptions regarding children's pain and pain medication; and (iii) to examine parents' perceptions of discharge advice. Family interviews with inductive content analysis were used to gather information from families of 17 Finnish children undergoing minor outpatient surgery at a university hospital in Finland. Versatile methods were employed by the parents in the identification and management of children's postoperative pain subsequent to discharge from the hospital. The children expressed that they had experienced pain relief through the administration of pain medication, eating ice-cream and playing. The results indicate a need for further research in order to identify what elements of parents' perceptions of children's pain and pain medication should receive additional attention. In addition, the content, methods of providing and timing of discharge advice need to be developed in order to help parents with their efforts to achieve maximum pain relief in children after surgery.     

The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital

OBJECTIVES: Although a great variety of surgical procedures are performed on an ambulatory basis, little is known about postoperative pain experience at home after ambulatory surgery. This study was performed to assess the prevalence and course of postoperative pain in the early postoperative period after ambulatory surgery. METHODS: Over a period of 4 months, 648 patients who underwent day-case surgery were included in our study. Data were collected with interviews and questionnaires. Pain intensity was measured using a visual analog scale (VAS) during 4 days after surgery. Side effects of anesthesia and analgesia techniques were also recorded. RESULTS: On the day of the operation, 26% of the patients had moderate to severe pain (defined as mean VAS >40 mm). Mean VAS-scores were greater than 40 mm in 21% on postoperative day (POD) 1, in 13% on POD 2, in 10% on POD 3, and in 9% on POD 4. Operations of nose and pharynx, abdominal operations, plastic surgery of the breasts, and orthopedic operations were the most painful procedures during the first 48 hours. DISCUSSION: This study showed that an important number of patients still experience moderate to severe pain in the postoperative period after day-case surgery even after a 4-day period. Furthermore, the type of operation should be considered when planning postoperative analgesia for ambulatory surgery.     

Surgery: not just for hospital anymore. Part I: Responding to the surgical patient in distress

The number of surgical and diagnostic procedures performed on an outpatient basis continues to grow in the U.S. These procedures are often performed in an ambulatory surgery center (ASC) or physician's office. While outpatient surgery is typically safe, a wide variety of complications can occur. When an emergency occurs in these facilities, the patient requires emergency treatment and may need to be transferred to a hospital for additional care. This article examines the types of emergencies that occur and the associated patient care requirements, including the special needs of intraoperative and postoperative patients and their interactions with healthcare providers.     

Inhalational anesthesia during adenoidectomy in children

The paper deals with the comparison of inhalational anesthesia using a fluoroethane-monooxide-oxygen mixture in apparatus-mask and endotracheal fashions in children during adenotomy. Children aged 4 to 15 years, who had undergone apparatus-mask (n = 51) and endotracheal (n = 57) anesthesia, were examined. The patients were divided into two age groups: 4-8 years and 8-15 years. The parameters of central hemodynamics, the data of cardiointervalograms, respiration rate, and SatO2 were studied. The studies were repeated 5 times for each patient at the stages of anesthesia and surgery. The use of inhalational fluroethane-monoxide-oxygen anesthesia in apparatus-mask and endotracheal fashions was found to be inadequate in children during adenotomy without addition of analgesics. In 4-8-year-old children, apparatus-mask fluoroethane-monooxide-oxygen anesthesia during surgery is ineffective, as shown by the data of central hemodynamics and cardiointervalography. The pain syndrome was observed in the postoperative period. Endotracheal fluoroethane-monooxide-oxygen anesthesia fails to ensure adequate analgesia during intubation and surgery. The pain syndrome and sympathicotony were seen in the postoperative period. In 8-15-year-old children, apparatus-mask fluoroethane-monooxide-oxygen anesthesia is characterized by prehypoxia and inadequate anesthesiological defense at the traumatic stage of an operation. In endotracheal fluoroethane-monooxide-oxygen anesthesia, the stability of cardiac output is maintained by the tension of more mature compensatory mechanisms responsible for regulation of central hemodynamics. A marked sympathicotony is noted at the traumatic stage of a surgery, as evidenced by cardiointervalography. There is motor agitation in the postoperative period.     

Pediatric ophthalmology and anesthesia pearls in the operating room

Providing nursing care to pediatric patients is both challenging and rewarding. The pediatric ophthalmic caregiver must remain acutely aware of physiologic changes, which may be subtle. Though most pediatric procedures are performed by an anesthesiologist using general anesthesia, the ophthalmic nurse needs to remain vigilant. Problems that arise must be attended to within mere seconds. This paper discusses distraction techniques and gives an overview of the care provided to children under general anesthesia at a major pediatric specialty hospital. This paper relates one ophthalmic nurse's experiences in a hospital-based outpatient surgery center that employs 14 board-certified faculty pediatric anesthesiologists as well as rotational anesthesia residents in their first, second, third, and fellowship years. The outpatient center has five operating rooms, and the inpatient surgery area has 14 operating rooms. Nearly 800 pediatric ophthalmology procedures are done in the outpatient area each year; approximately 20 ophthalmology procedures are done at the inpatient surgery area annually.     

Surgery: not just for hospitals anymore. Part 2: EMS response to postoperative complications

Patients who have undergone a surgical procedure at an ambulatory surgery center, hospital or physician's office may experience postoperative complications. This article examines the types of postoperative complications that can occur following outpatient procedures, with recommendations for EMS patient care and issues related to patient transport.     

Comparison of Analgesic Efficacy of Local Anesthetic Infiltration and Ultrasound-guided Abdominal Wall Nerve Block in Children Undergoing Ambulatory Inguinal Hernia Repair

PurposePlacement of local anesthetics either as infiltration (LAI) or as abdominal wall nerve block (AWNB) has been shown to reduce postoperative pain following laparoscopic surgery. We aimed to compare intraoperative remifentanil consumption and postoperative pain of AWNB and LAI in children undergoing ambulatory two-port laparoscopic inguinal hernia surgery with propofol-remifentanil based general anesthesia.DesignRandomized controlled trial.MethodsChildren aged between 1 and 6 years undergoing two-port laparoscopic inguinal hernia repair were enrolled for analysis. These children received one of the three anesthesia regimens (1) standard general anesthesia (SGA); (2) SGA with preemptive LAI; (3) SGA with preemptive AWNB; and were categorized accordingly. Primary outcome variable were intraoperative average infusion rate of remifentanil and postoperative FLACC (Face, Legs, Activity, Cry, and Consolability) pain score. Secondary outcome data included demographics, intraoperative variables (hemodynamics and bispectral index score recorded at three different time points), and duration of surgery.FindingsA total of 90 children (30 in each group) were included in the analysis. General information, intraoperative hemodynamic variables, bispectral index score, and duration of surgery were not significantly different among groups. The intragroup variation of hemodynamic variables were less stable in the SGA group compared with the other two groups, while BIS score was similar among groups. The intraoperative infusion rate of remifentanil was significantly lower in the AWNB group than in the SGA or the LAI group (median [25th to 75th centiles]: 0.11[0.11 to 0.11] µg/kg/min, 0.33[0.33 to 0.33] µg/kg/min; 0.17[0.17 to 0.20] µg/kg/min, respectively, P < .001 for both), and lower in the LAI group than in the SGA group (P < .001). The postoperative FLACC pain score was significantly lower in the AWNB group than in the SGA or the LAI group (P < .001 for both).ConclusionsAWNB is associated with a lower intraoperative remifentanil requirement and a lower postoperative FLACC pain score compared with LAI in children undergoing laparoscopic inguinal hernia repair with propofol-remifentanil based general anesthesia.     

Patient care after discharge from the ambulatory surgical center

An important and often forgotten aspect of postoperative care occurs after the patient is discharged from the ambulatory surgical center. With more than 60% of all surgeries and procedures occurring on an ambulatory basis, what happens after the patient is no longer in continuous professional care is of concern to the ambulatory nurse. Numerous physical postoperative complaints are common and expected sequelae of anesthesia and surgery in the ambulatory patient. In this article, important postdischarge complications are reviewed and contemporary management options discussed. The information contained in this review article is valuable to the provider in educating patients regarding their anticipated course of postoperative recovery. OBJECTIVES: -Based on the content of this article, the reader should be able to (1) identify important postdischarge complications to provide patients with comprehensive discharge instructions regarding their continued recovery at home; (2) discuss contemporary management options available to treat postdischarge complications; (3) realize the incidence of specific postdischarge complications and how that relates to patient satisfaction with the surgical experience; (4) recognize signs and symptoms of postdischarge complications; and (5) identify risk factors of patients for developing specific complications in the postoperative phase.     

I Can’t Read That! Improving Perioperative Literacy for Ambulatory Surgical Patients

Low literacy and low health literacy are surprisingly rampant problems facing health care providers. Patient educators in all settings should consider the need for improved patient education materials that are easy to read and understand for the majority of patients. In the ambulatory surgery setting, patients often have time to prepare for scheduled outpatient surgery, yet education is provided primarily in the postoperative period. This article highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction in the ambulatory surgery setting.     

Continuous peripheral nerve blocks

Sophisticated regional anesthesia techniques have experienced substantial growth throughout the past 5 years for acute and chronic pain management. The recognition that regional anesthesia leads to superior postoperative outcomes in acute pain management and to an increased understanding of the pathogenesis of chronic pain has led to increased use of continuous peripheral nerve catheters. Furthermore, the availability of new equipment and techniques specifically designed to facilitate effective catheter placement has increased interest and adoption of peripheral nerve catheters to manage painful conditions. This has become particularly relevant as the scope of ambulatory surgery continues to grow. To maximize success rates with continuous peripheral nerve catheters, clinicians must be intimately aware of the pertinent regional anatomy and technical issues surrounding placement and maintenance of continuous nerve blockade. The recent development of outpatient infusion systems and novel anesthetics has been exciting and is likely to lead to an increase in the use of continuous peripheral catheter techniques. The consistent recognition that these techniques dramatically increase patient satisfaction should dictate an increasing presence in the field of pain management throughout the next several years.     

儿童扁桃体挤切术和剥离术的对比分析

目的 :探讨扁桃体切除的术式选择。方法 :对 12 36例使用挤切法或剥离法行扁桃体切除术的儿童进行回顾性研究。剥离术在全麻下进行 ,挤切术用局麻或表麻。结果 :两种术式发生出血的最高比例是在术后 4 .5h内 ,行剥离术组中约 1.6 %的病人出现严重出血体而需外科处理 ,但挤切术组未发现现象。结论 :经正确选择的儿童在局麻下行扁桃体挤切术安全、省时、有效     

成人日间手术加速康复外科麻醉管理专家共识

中国日间手术合作联盟定义的日间手术是指患者在一日(24 h)内完成入、出院的手术或操作(不含门诊手术), 对于特殊病例由于病情需要延期住院的患者, 住院最长时间不超过48 h。加速康复外科是以循证医学证据为基础的围手术期优化措施, 有助于减少手术应激与炎症反应, 促进患者快速康复, 提高患者围手术期安全性和舒适性。基于日间手术住院时间短、床位周转率高的特点, 加速康复外科理念下的麻醉管理为日间手术安全、舒适和高效发展奠定了基础。     

Combined anesthesia using Diprivan and ketamine in pediatric surgery

A total of 120 children aged 7-14 years were subjected to short-term elective and urgent interventions under combined intravenous anesthesia with diprivane and ketamine. The patients were divided into groups depending on methods of general anesthesia. Noninvasive monitoring of hemodynamic parameters and SaO2 was carried out during anesthesia and surgery and psychomotor functions were evaluated during the immediate postoperative period. Ketamine ensured stable hemodynamics during induction anesthesia. A combination of diprivane and ketamine levelled some untoward effects of these anesthetics.