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Correspondence |
University of Pittsburgh School of Medicine, Pittsburgh, USA, E-mail: williamsba.upmc{at}gmail.com
To the Editor:
We were very interested in reading the excellent publications of Dr. Song et al.1 and Dr. Awad et al.2 from Dr. Chung’s research group addressing bypass of the postanesthesia care unit (PACU bypass) after ambulatory surgery. Specifically, they advise that PACU bypass may merely shift nursing workload from the PACU to the phase 2 recovery unit (P2RU). As background, we originally reported in knee surgery outpatients that in addition to PACU bypass [odds ratio (OR) = 2.9], other factors were independently associated with the need for at least one P2RU nursing intervention, including general anesthesia with volatile agents (OR = 1.5), and receiving indicated nerve blocks (OR = 0.6).3 We later reported that PACU bypass was independently associated with approximately $400 cost savings to the hospital, per knee surgery outpatient having undergone anterior cruciate ligament reconstruction.4
In our 2002 report,3 we overlooked the variable of multimodal antiemetic prophylaxis and the specific effect of postoperative nausea and vomiting (PONV) on P2RU workload. We later reported5 that multimodal antiemetic prophylaxis with two or more agents (perphenazine and dexamethasone in over 90% of cases) reduced all postoperative nursing interventions for PONV after regional anesthesia. It seems unlikely that multimodal antiemetic prophylaxis would increase P2RU workload, and the use of volatile anesthetics associated with increasing P2RU workload has already been established in our retrospective study3 and in the 2004 prospective study by Dr. Song et al.1
We also need to reiterate that our original report3 addressed only outpatient knee surgery, and that not all outpatient orthopedic surgery is knee surgery (knee pain originates from 1, 2, or 3 nerves). Outpatient shoulder surgery in our institution is routinely performed under interscalene nerve block and propofol infusion without volatile agents or airway devices. We previously reported5 that this care plan was associated with a 9% PONV rate (13/146) when perphenazine and dexamethasone were used as multimodal antiemetics, and a 16% (50/303, P < 0.005) PONV rate when one or fewer antiemetics were used. After additional query of our original database of these 449 shoulder surgery outpatients, we found that PACU bypass rate was 94%. There was no associated increase in the need for any P2RU nursing interventions after PACU bypass, but this finding is likely underpowered due to the low incidence of PACU admission. However, antiemetic prophylaxis with perphenazine and dexamethasone in these patients was associated with a reduced need for P2RU intervention by 50%. Hospital discharge times were 162 min (151, 173, 95% confidence interval) in patients receiving perphenazine-dexamethasone, vs 178 min (169, 186; P = 0.034) in patients who did not receive perphenazine-dexamethasone. These anecdotes from our quality-control database query are not peer reviewed. These data should not be interpreted as anything except reasonable justification for continued hypothesis testing regarding the role of volatile agent avoidance and multimodal antiemetic prophylaxis, in an effort to achieve both PACU bypass, without additional increases in P2RU workload.
We are not surprised by findings of authors such as Dr. Song et al. that PACU bypass leads to increased P2RU workload both after general anesthesia,1 and in the absence of a routine peripheral nerve block that would provide near-complete analgesia for the area of surgical trespass.1 We also believe that success with PACU bypass (i.e., preventing downstream workload) may be improved by the routine administration of multimodal antiemetics, regardless of calculated risk.5 Further study is encouraged.
Footnotes
Funding was provided strictly by departmental support.
Accepted for publication December 14, 2006.
References
1 Song D, Chung F, Ronayne M, Ward B, Yogendran S, Sibbick C. Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery. Br J Anaesth 2004; 93: 768–74.
2 Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anesth 2006; 53: 858–72.
3 Williams BA, Kentor ML, Williams JP, et al. PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions. Anesthesiology 2002; 97: 981–8.[Medline]
4 Williams BA, Kentor ML, Vogt MT, et al. The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated post anesthesia care unit bypass and same-day discharge. Anesthesiology 2004; 100: 697–706.[Medline]
5 Kentor ML, Williams BA. Antiemetics in outpatient regional anesthesia for invasive orthopedic surgery. Int Anesthesiol Clin 2005; 43: 205–13.[Medline]
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