Fast-Tracking and Modified Aldrete Score

Vimmi Kang, DO

New Criteria for Fast-Tracking After Outpatient Anesthesia: A Comparison with the Modified Aldrete’s Scoring System

Paul F. White, PhD, MD, FANZCA and Dajun Song, MD, PhD

A & A May 1999 vol. 88 no. 51069-1072

The modified Aldrete’s scoring system is commonly used for determining when patients can be safely discharged from the PACU to either the postsurgical ward or to the second stage (Phase II) recovery area. Recently, these discharge criteria have also been used in the OR to determine the fast-track eligibility of outpatients undergoing ambulatory surgery. The modified Aldrete’s scoring system is a highly acceptable criteria for discharging patients from the PACU. However, this scoring system was not designed to assess the patient’s ability to bypass the PACU after major ambulatory procedures under general anesthesia. So a new criteria was compared to the modified Aldrete scoring system to see which one was more structured to fit fast tracking after outpatient anesthesia.

Recovery data from 216 consenting female outpatients undergoing either laparoscopic tubal ligation or cholecystectomy procedures at the University of Texas Southwestern Medical Center at Dallas from January 1997 through July 1998 were analyzed. General anesthetics were either maintained by inhaled anesthetics (desflurane, sevoflurane) or Propofol. Early recovery status was evaluated at 1-min intervals after termination of the anesthetics using both the modified Aldrete scoring system  and the new fast-track scoring system. Patients were considered fast-track–eligible if they achieved a score of 10 using the modified Aldrete scoring system or a score of ≥12 (with no score <1 in any individual category) using the new scoring system.

In conclusion, The results from this data evaluation demonstrated that 22%–29% of outpatients judged fast-track–eligible using the modified Aldrete scoring system subsequently required IV analgesics and antiemetics. Although these patients were fully oriented and had stable vital signs, they would have added to the workload of the Phase II nursing staff and may have necessitated the use of more extensive monitoring in the step-down unit. So, the new fast-track scoring system seems to offer advantages over the modified Aldrete’s scoring system in evaluating the suitability of outpatients for bypassing the PACU after undergoing ambulatory surgery with general anesthesia.

Complications PACU, Dr. Kang

Vimmi Kang, DO

Summary of “Complications Occuring in the Postanesthesia Care Unit: A Survey”

Hines R., Barash P., Watrous, G and Theresa O’Connor. “Complications Occuring in the Postanesthesia Care Unit: A Survey” Anesth Analg 1992;74:503-9.

            The main objectives of the article was to identify the complications that occurred in PACU, the incidence of those complications in PACU and intraoperative, and determine the variables associated with a greater risk of developing PACU complications.  This was a prospective study looking at 18,473 patients in a PACU setting at a university teaching hospital.

            The study showed the incidence of intraoperative events only to be 5.1%, Postoperative events to be 23.7%, and the combined intraoperative and postoperative events to be 26.7%.

            The incidence of events were analyzed and found to have complications mostly associated with nausea and vomiting (9.8%), need for upper airway support (6.9%) and hypotension requiring treatment (2.7%).

            The study also examined the variables associated with greater risk of developing complications. These variable were determined to be ASA II status, duration of anesthesia (2-4hr), anesthetic technique (general anesthesia associated with higher complication rates versus regional or monitored anesthetic), emergency procedures, and certain types of surgical procedures (orthopedic or abdominal).

            Temperature was also found to prolong stay in PACU. A temperature less than 35 degrees Celsius resulted in average stay of 152 minutes versus 116 minutes in patients with a temperature greater than 36 degrees Celsius. 

            ICU patients were excluded from this study and participation was at the discretion of the attending anesthesiologist.

            An important point to be made prior to concluding is that the article found ASA II to be more of a risk factor than ASA III or IV, which could be related to the fact that most of the patients were ASA II to begin with and most of the patients that were ASA III or IV were directly taken to ICU and thus excluded from the study.

Complications Occurring in the Postanesthesia Care Unit

http://www.anesthesia-analgesia.org/content/74/4/503.full.pdf+html

Anesthesia and Acute Spinal Cord Trauma, Dr. Kang

Vimmi Kang, DO

 Dooney N, Dagal A.  Anesthetic considerations in acute spinal cord trauma. Int J Crit Illn Inj Sci 2011;1:36-43

This article reviews the anesthetic considerations for spinal cord trauma. It starts off defining primary and secondary injury. Primary being the injury that occurs at time of injury and secondary injury is what develops within minutes like inflammation and edema.

Techniques for airway management  that are discussed are  manual in line stabilization and rigid collar during larngoscopy. Manual in line stabilization provides a better view on DL than using a rigid collar. Patient is also easier to mask during ventilation. It was also stressed to provide the least amount of jaw thrust and chin lift to minimize any compression to the cervical spinal.

Succinylcholine should be avoided from three to nine months after spinal cord injury.  Rocuronium is a safe alternative.

The next section discusses blood pressure management. Spinal cord perfusion pressure is  autoregulated just like cerebral perfusion pressure and thus  maintained over a range of systemic blood pressures.

Fluid Management of colloids versus crystalloid is still a debate.  Hypotonic crystalloids may worsen edema and cord swelling and thus should be avoided. Albumin use is relatively contraindicated due to study from SAFE-TBI of increased mortality in patients with traumatic brain injury.

Lastly, on the discussion of corticosteroids it was stated that the use of steroids after reviewing risk and benefits is the not the standard of care, just a treatment option.

Will Aspirin prevent acute lung injury in critically ill patients? Dr. Kang

Vimmi Kang, DO

Article Review

The effect of aspirin in transfusion-related acute lung injury in critically ill patients

Source: Anesthesia. 20012 FEB 11

            This article looked to examine if aspirin would protect against transfusion related acute lung injury in critically ill patients. This article stemmed from the recent models that showed aspirin to be beneficial in improving outcomes in transfusion related injury in animals. This study was conducted as a post analysis of a case-control study. It looked at Transfusion-related acute lung injury cases compared with the control. Study consisted of 218 patients of which 66 used aspirin. Results showed that use of aspirin did not change the risk of transfusion related acute lung injury after transfusion of platelets or plasma.

In conclusion, aspirin did not decrease or protect against transfusion-related acute lung injury in critically ill patients.