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OUTPATIENT SURGERYDr Masood Entezari Asl

OUTPATIENT SURGERY

outpatient (ambulatory, day-case, same-day, come-and-go) surgery and anesthesia continue to evolve in scope and complexity throughout the world.

Multimodal regimens for the management of postoperative pain, nausea, and vomiting promote more timely discharge, a better quality of recovery, and greater patient satisfaction.

OUTPATIENT SURGERY

The elements of care that provide for safe and uncomplicated anesthesia in the outpatient venue are no less important when the patient is to be discharged after an overnight hospital stay.

Sites for outpatient surgery include main operating room complex or separate operating rooms within a hospital, a separate facility physically attached to a hospital or on hospital grounds, or a hospital-independent facility (freestanding "surgicenter.")

OUTPATIENT SURGERY Such procedures commonly involve children and

include : radiation therapy interventional radiologic procedures neuroradiologic interventions compute tomography(CT)/magnetic resonance

imaging(MRI) endoscopy examination under anesthesia auditory evoked potentials electroretinography bone marrow biopsy intrathecal drug therapy

ADVANTAGES OF OUTPATIENT SURGERY

1. Decreased medical costs2. Increased availability of beds for patients

who require hospitalization3. Protection of immunocompromised patients

from hospital-acquired infections4. Avoidance of disruption of the family unit

by hospitalization.

Cost savings may extend beyond actual medical expenses in as much as patients can often return to daily activity or work sooner.

An alternative to the same-day surgical concept is a planned overnight admission to the hospital after surgery.

OFFICE-BASED ANESTHESIA Patient preference, convenience, and

privacy, along with theoretically reduced expenses, are the public's push behind this trend.

Surgeons enjoy convenience and control over a lower overhead.

reduce their costs. Today, virtually every medical and surgical

discipline has its office-based procedures. The escalating scope and complexity of

office-based procedures make provision of monitored anesthesia care (MAC), regional anesthesia, or general anesthesia an increasingly common requirement.

PATIENT SAFETY CONSIDERATIONS The public deserves and expects a single safety and quality

standard of anesthetic and surgical care regardless of venue

When outpatient surgery is performed in a freestanding facility or the physician's office, a transfer and admission agreement with a nearby affiliated hospital must be in place should unexpected hospitalization be required in the immediate perioperative period.

The need to deliver a safe anesthetic with minimal undesirable side effects and rapid recovery is critically important for office-based surgery. Short-acting, fast emergence (SAFE) anesthetics such as propofol, remifentanil,desflurane, and sevoflurane facilitate timely achievement of discharge criteria.

Regional anesthesia with longer-acting local anesthetics can provide excellent analgesia during surgery and effective postoperative pain relief for complex surgical procedures.

FACILITIES operating rooms, anesthetic equipment, and recovery

facilities used for outpatient surgery not differ in quality from those used for inpatient surgery.

Policies and procedures should be consistent staff should possess equivalent skills and be equally

competent. staff must be capable of permitting patients to remain

for several hours after surgery if needed. Having a medical director, often an anesthesiologist,

who is responsible for the medical care delivered in the facility.

Administrative responsibility may be the medical director's or be under the purview of an individual with administrative expertise.

PATIENT SELECTION

Selection of individuals for outpatient surgery was determined by :

1- the characteristics of the patient 2- the type of operation other elements :

- the psychosocial aspects of the patient

- human and physical resources for preoperative and

postoperative care

- proximity to emergency care

- resources of the facility

- the skill set of both the surgeon and the anesthesiologist

CHARACTERISTICS OF THE PATIENT

Many patients are in good general health Having systemic diseases (non-insulin

dependent diabetes mellitus, essential hypertension, seizure disorder, asthma) that are controlled

As outpatient surgery continues to expand in scope, more patients will have severe conditions

The development and application of less invasive surgical techniques and better anesthetic regimens have promoted the performance of more complex procedures in those more infirm.

CHARACTERISTICS OF THE PATIENT

The venue the night after surgery will have proximity to emergency care

Patient or caretaker competence and proximity to emergency care may permit discharge

PEDIATRIC PATIENTS

Age is not a factor in the selection of patients Many operations and diagnostic/therapeutic

procedures in children are amenable to being performed on an outpatient basis

POSTOPERATIVE APNEA

The age at which premature or full-term infants can safely undergo surgery and return home remains controversial

the subsequent incidence of apnea after inguinal herniorrhaphy was not less than 5% until post conceptual age was 48 weeks and gestational age was 35 weeks.

Any infant with apnea in the PACU or anemia, regardless of age, should be admitted to the hospital

ELDERLY PATIENTS

More important than advanced age is the medical control of diseases often associated with aging, as well as provision for social and physical support of the elderly patient both before and after surgery and anesthesia.

TYPES OF PROCEDURES Procedural factors may predict prolonged PACU stay or

unplanned admission to the hospital Such factors include intraoperative blood loss and duration

of the procedure. Patient or caregiver (parent/guardian) sophistication and

competence may facilitate discharge in one case and prevent it in another.

Postoperative complications that might require intensive physician or nursing management should be very rare.

Pain should be Manageable Postoperative nausea and vomiting (PONV) should be

minimal to absent. Operations that require major intervention into the cranium

and thorax remain unacceptable for outpatient surgery Infected patients and emergency surgery are "disruptive“

and not usually welcome in an outpatient facility.

PREOPERATIVE PREPARATION ANDINSTRUCTIONS TO THE PATIENT Coexisting medical conditions must be evaluated to

determine whether the patient's health is acceptable, in need of further evaluation, or in need of intervention.

Preoperative teaching Psychosocial issues can be even more important than

medical issues Examples : - third-party authorization for the procedure - transportation to and from the facility - local lodgings before and after surgery - access to a telephone - the ability to understand and follow instructions - the availability of translation services - proximity to emergency care - the competence of the patient's supportive network

TIMING OF PREOPERATIVE EVALUATION

Sick patients or those with psychosocial issues are best identified early in the process (days before)

Some systems rely on the surgeon to identify such patients

Others ask that at least the patient's history be made available beforehand so that the anesthesiologist can make a determination.

HISTORICAL INFORMATION Historical information is often obtained through an

oral, written, or electronic questionnaire The questionnaire can be self-administered or

administered by trained staff, a registered nurse, a nurse practitioner, a nurse anesthetist or an anesthesiologist

Security of confidential information is one of the major concerns.

Medical conditions may require active intervention and management or just awareness.

Examples commonly include poorly controlled systemic hypertension, diabetes, anticoagulation, and chronic pain

MEDICATIONS Most medications should be continued Adjustment for Insulin, oral hyperglycemic agents,

diuretics, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and some psychiatric medications

Taking an oral drug with a sip of water Patients who require food along with their medication

present an issue that must be dealt with on an individual basis.

Preoperative interventions now common to inpatient care:

- perioperative βblockade for ischemia - medications or compression devices for

thrombosis - aggressive glucose control

ORIENTATION TO THE FACILITY

Providing information through a tour, video, or web-based material.

If parents are allowed to be present for induction of anesthesia, they should be educated so that they have realistic expectations of the experience.

LABORATORY DATA REQUIRED PREOPERATIVELY

depend on : the patient's age, medical history, physical examination, current drug

therapy. Routine laboratory tests in the absence of

positive findings on the history or physical examination are not usually warranted.

PATIENT INSTRUCTIONS

Instructions should be provided in writing or at least by telephone in the relevant

language It is best to contact the patient or caretaker

Arriving 1 to 2 hours before the expected time of surgery

Patient with a higher cancellation rate (children and the mentally challenged) may

also be asked to arrive earlier.

Information Often Provided on the Written Instruction Sheet Given to Patients When Outpatient Surgery is Scheduled

Verify that the requested laboratory tests are completed

Fasting for solids for 6 hours or longer

Clear fluids are permissible up to 2 hours before induction of anesthesia as approved by the anesthesiologist

What medications to take (or not take)

Bring inhalers and sleep apnea devices

Wear minimal to no cosmetics or jewelry

Where and when to report for surgery and estimate of discharge time

Must be accompanied by a responsible adult to provide transportation home

Notify the surgeon if there is a change in the patient's medical condition before surgery

After surgery, resume eating when hungry, starting with clear liquids and progressing to soups and then a regular diet

Do not drive an automobile (or other mechanized equipment), make important decisions, or ingest alcohol or depressant drugs for 24 to 48 hours

Telephone number to contact a nurse or physician regarding postoperative complications

FASTING Clear fluids (water, black coffee , clear tea, pulp-free

juice, carbonated beverage) in reasonable volumes up to 2 hours before induction of anesthesia. Breast milk up to 4 hours before induction

Infant formula up to 6 hours light meal (dry toast, milk) up to 6 hours before

induction Consideration for conditions (gastroparesis) that

slow the transport of food through the gastrointestinal tract

In practice, misunderstanding or failure to follow fasting instructions is a very common reason for

cancellation or postponement of surgery

ARRIVAL ON THE DAY OF SURGEYR

Compliance with preoperative instructions is verified particularly with respect to the ingestion of solid food and clear liquids

Preoperative database including the patient's health history and physical examination, indicated laboratory or study results, and surgical consent must be rechecked for completeness

CHECK-IN PROCEDURE State requirements for timeliness of the

history and physical examination vary : - within 7 days of the procedure. - At the time of surgery - within 24 hours of surgery A check-in procedure confirms : - the identification of the patient - the nature of the procedure - the surgical site Patients change into a gown if indicated, NPO

times are confirmed, vital signs are obtained, and if indicated, an intravenous catheter is inserted.

ROLE OF THE ANESTHESIOLOGIST

reviewing the patient's medical record, laboratory data, and surgical consent and verifying the site of

surgery Vital signs are noted and current medications and

medication allergies reviewed pediatric patients must be thoroughly evaluated for

the recent onset of an upper respiratory tract infection

PEDIATRIC PATIENTS AND RHINORRHEA

Benign rhinorrhea is usually an allergic rhinitis that does not contraindicate elective surgery

An ill appearance and a body temperature higher than 38°C are suggestive of an infectious rather

than a noninfectious process

PREOPERATIVE MEDICATION preoperative medication for ameliorating anxiety

and addressing preoperative discomfort Additional medication acutely to treat systemic

hypertension, institute β-blockade , treat bronchoconstriction, prevent infection

(prophylactic antibiotics), control blood glucose concentrations, and provide corticosteroid coverage.

Drugs administered for preoperative medication should neither delay recovery from anesthesia nor

produce excessive amnesia. Fentanyl (1.0 чg/kg IV) and midazolam (0.04 mg/kg IV) administered before induction of anesthesia tend

to decrease anesthetic requirements and airway irritability and do not delay recovery.

PEDIATRIC PATIENTS

The need for pharmacologic premedication may be less if the parents are calm and can

participate in the induction of general anesthesia or physical transfer of the child to

the nurse or anesthesiologist Preoperative administration of midazolam

(0.5 to 1.0 mg/kg orally or rectally) is effective in promoting separation from the parents within 20 to 30 minutes and is not

associated with delayed recovery

MENTALLY CHALLENGED PATIENT

Uncooperative, mentally challenged adults pose unique issues because they cannot be physically manipulated as easily as children

Some will cooperate and accept insertion of an intravenous catheter

Others may cooperate with inhalation induction of anesthesia

Regimens include midazolam, up to 20 mg orally, ketamine, 2 to 3 mg/kg

intramuscularly, or a combination of midazolam (0.3 mg/kg) and ketamine (2

mg/kg) intramuscularly

GOALS

Preoperative medication intended to decrease preoperative anxiety in adults is most often provided by the administration of small doses of midazolam (1 to 2 mg IV)

Sedation can be produced by the oral administration of a benzodiazepine such as diazepam

Unmedicated patients may walk to the operating room, whereas others may be transported by gurney or wheelchair.

PROPHYLAXIS AGAINST POSTOPERATIVE NAUSEA AND

VOMITING A prophylactic antiemetic (serotonin antagonists,

corticosteroid) may be useful for patients who : (1) have a history of PONV

(2) are subject to motion sickness (3) are undergoing operations associated

with a high incidence of PONV. The routine use of prophylactic antiemetics remains controversial because a large percentage of patients

do not experience nausea and vomiting As with inpatients, outpatients considered to be at risk

for pulmonary aspiration may receive preoperative pharmacologic therapy intended to speed gastric

emptying, increase gastric fluid pH, or decrease gastric fluid volume. Any antacid administered orally should

be clear, not particulate.

USE OF ANTICHOLINERGICS

an antisialagogue effect may be useful before procedures involving the oropharynx, where excessive secretions could interfere with the production of topical anesthesia.

TECHNIQUES OF ANESTHESIA All techniques of anesthesia (general anesthesia,

regional anesthesia, local anesthesia with or without sedation, and MAC) and most drugs available to inpatients are also appropriate for outpatients.

Prompt and nearly complete recovery with minimal side effects (residual sedation, PONV; orthostatic

hypotension, pain) is ideal Expense may be a factor in the choice of anesthetics The cost of sedation is usually less than the cost of a

general anesthetic. The incidence of PONV tends to be less after local anesthesia and MAC than after general anesthesia

Awakening is usually more rapid after local anesthesia and MAC than after general anesthesia

The safety of modern ambulatory anesthesia is impressive, and the complications that occur in these

patients are generally easily managed and self-limited

GENERAL ANESTHESIA General anesthesia is frequently selected for outpatient

surgery. Its onset is fast and it can be controlled easily

Administration of so-called SAFE drugs for general anesthesia

Propofol has become the induction drug of choice for patients undergoing outpatient surgery despite the

availability of alternative drugs (thiopental, etomidate). Psychomotor recovery is more rapid after induction of

anesthesia with propofol have less nausea and vomiting

patients may experience euphoria on emergence from propofol anesthesia, especially when combined with the

ultrashort-acting opioid remifentanil Etomidate is associated with rapid awakening, but the increased incidence of myoclonic movements and PONV

detracts from its use for outpatients.

INDUCTION OF ANESTHESIA IN PEDIATRIC PATIENTS

Facilitating cooperation for inhalation induction of anesthesia by :

- Introduction to the facemask - choice of "flavored medicine“

- parental presence - involvement of the child in a game or story

- premedication With skill, a small-gauge intravenous catheter can be placed

with minimal discomfort When inhalation induction of anesthesia is planned, the most

frequently selected drug is Sevoflurane Sevoflurane does not cause airway irritation

Poor solubility in blood permits more rapid achievement of an anesthetizing concentration than is possible with halothane

Postoperative delirium in children may result from the rapid offset of drugs such as sevoflurane.

AIRWAY ADJUVANTS Facemasks and oral airways may be used during

anesthesia for brief and superficial surgical procedures

The laryngeal mask airway (LMA) and other supraglottic airway devices have completely

changed airway management for such patients In comparison with tracheal intubation, use of an

LMA does not require neuromuscular blocking drugs nor their antagonism

An LMA tends to be less irritating, and placement is associated with a smaller hemodynamic response and a smaller rise in intraocular

pressure The original LMA Classic does not protect the airway from aspiration, and the use of positive-

pressure ventilation may be questionable The LMA ProSeal attempts to address both issues.

TRACHEAL INTUBATION

Some patients and procedures require tracheal intubation

A disadvantage of succinylcholine in outpatients is the occasional occurrence of myalgia.

Spontaneous recovery from the effects of mivacurium is prompt

Atracurium, cisatracurium, vecuronium, and rocuronium are somewhat longer-acting

alternatives Some believe that any nondepolarizing

neuromuscular blockade should be antagonized Others feel comfortable if the blockade has fully

resolved spontaneously as reflected by neuromuscular blockade monitoring or clinical criteria.

MAINTENANCE OF ANESTHESIA

Maintenance of anesthesia is often achieved with the combination of nitrous oxide and a volatile anesthetic

(desflurane or sevoflurane) Nitrous oxide may be avoided based on the concern

that this gas promotes PONV An alternative to volatile anesthetics for maintenance of anesthesia is the continuous intravenous infusion of

propofol, usually with an adjunct such as fentanyl, remifentanil, or ketamine.

Total intravenous anesthesia (TIVA) techniques avoid all inhaled anesthetics and may include a

neuromuscular blocking drug Inhaled and intravenous anesthetics are not mutually

exclusive, and many use them in combination.

ANALGESIA Analgesia is best provided by the use of a local anesthetic

administered by : - infiltration

- nerve block - plexus block

- intra-articular - intracavitary

- topical Opioids such as fentanyl and meperidine have traditionally been

used to provide perioperative analgesia Such drugs are associated with side effects, including respiratory

depression, drowsiness, PONV, pruritus, and urinary retention-each of which can delay discharge and produce dissatisfaction

Analgesic modalities include NSAIDs, acetaminophen, ketamine, and a2 agonists such as clonidine and dexmedetomidine

Severe postoperative pain in adults may require acute treatment by the intravenous administration of an opioid such as fentanyl,

meperidine, or hydromorphone. Severe, protracted pain remains a common reason for

unanticipated hospital admission after planned outpatient surgery

POSTOPERATIVE NAUSEA AND VOMITING

Treatment of severe postoperative vomiting may include the rescue administration of ondansetron,

dexamethasone, promethazine, or dimenhydrinate For motion-related PONV some find intramuscular

hydroxyzine or ephedrine (or both) efficacious Protracted PONV is a common reason for prolonged

time in the PACU or unanticipated hospital admission after planned outpatient surgery.

REGIONAL ANESTHESIA

Regional anesthetic techniques in outpatient surgery:

- peripheral nerve blocks (femoral, median, sciatic nerve)

- combination of peripheral nerve blocks (ankle, hand block)

- brachial or lumbar plexus blocks - neuraxial blocks (spinal and epidural) Performing a regional anesthetic may take longer

than inducing general anesthesia, and the possibility of failure exists.

TECHNIQUE Regional anesthesia may be used in combination with

intravenous sedation or general anesthesia Except in children, the administration of a neuraxial block

is not recommended when the patient is unconscious An unconscious patient cannot report pain or severe

paresthesia Adjuncts to improve the success and reduce the

complications associated with regional anesthesia include the use of an electrical stimulator with an insulated

needle and ultrasound guidance to localize the nerve. Recovery from the effects of a regional anesthetic

(sensory, motor, and sympathetic nervous system blockade) can take longer and delay ambulation when

compared with recovery from a general anesthetic

SPINAL ANESTHESIA Spinal anesthesia does not need to be avoided in outpatients

The use of very thin (>=25-gauge), rounded- or pencil-point needles reduces the incidence of post-dural puncture headache (PDPH)

The headaches are usually mild and self limited Many believe that early ambulation does not increase the

incidence of PDPH Epidural anesthesia may become a suitable alternative to

spinal anesthesia Prolonged spinal block can delay discharge and lead to patient

frustration and urinary retention in susceptible males. Epinephrine should not be added to the local anesthetic

solution lidocaine has been used for spinal anesthesia in the outpatient

setting because of its short duration of action Concern about painful transient radicular symptoms after

spinal anesthesia with lidocaine has reduced its popularity substantially

Procaine, mepivacaine, bupivacaine, ropivacaine, and levobupivacaine may provide alternatives to lidocaine

Concomitant administration of intrathecal fentanyl can also be useful

POSTOPERATIVE ANALGESIA Postoperative use of patient-controlled

analgesia or epidural local anesthetic/opioid infusions has not proved practical for analgesia after outpatient surgery

Indwelling peripheral nerve and plexus catheters that allow continuous instillation of low doses of local anesthetic solution may be used for postoperative analgesia after more complex procedures involving the extremities

Such techniques give the patient a reusable or disposable reservoir and pump to use at home

Patient and caretaker education about its proper use and potential complications is mandatory

SEDATION AND ANALGESIA Anesthesia for many outpatient surgical procedures, invasive

medical procedures, and diagnostic tests can be accomplished simply and effectively by the use of intravenous sedative-hypnotics and analgesics

MAC entails the administration of these drugs and monitoring of the patient's vital signs by an anesthesiologist

The combination of a regional anesthetic or local infiltration anesthesia with the intravenous injection of drugs to produce sedation or analgesia (or both) is particularly well suited for outpatient surgery.

Drugs commonly administered to adults to produce sedation and amnesia include midazolam or propofol

Continuous low-dose intravenous infusion of propofol (25 to 100 чg/kg/min) is particularly useful for producing sedation more painful procedures or when a peripheral nerve block requires supplementation, an opioid such as fentanyl (25 to 50 чg IV) or an infusion of remifentanil (0.075 to 0.15 чg/kg/min) or ketamine (5 to 20 чg/kg/min) may be useful

DISCHARGE FROM THE OUTPATIENTFACILITY Discharge from the outpatient PACU is based on

specific criteria and documentation that the residual effects of anesthesia have dissipated

More important is the use of criterion-based milestones to determine the propriety of discharge

Hospital-based outpatient facilities may admit postoperative outpatients to a PACU more suited for inpatient care (first stage or phase I)

When defined criteria are met, patients then transfer to a less intensive and acute care area where they may still recover on a gurney or flattened recliner (second stage or phase II)

Patients who meet these criteria in the operating room or very soon after leaving the operating room may be admitted directly to this phase II area (Table 36-2)

TABLE 36-2 FAST-TRACK CRITERIA FOR DIRECT TRANSFER FROM THE OPERATING ROOM TO THE PHASE II UNIT AFTER GENERAL ANESTHESIA

Score

level of Consciousness

Aware 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 extremities 1

Unable to voluntarily move extremities 0

Hemodynamic Stability

Systemic blood pressure <15% of baseline MAP value 2

Systemic blood pressure 15% to 30% of baseline MAP value

1

Systemic blood pressure >30% below baseline MAP value

0

Respiratory Stability

Able to breathe deeply 2

Tachypnea with good coughDyspnea with cough

10

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

No or mild discomfort 2

Moderate to severe pain controlled with IV analgesics 1

Persistent severe pain 0

Postoperative Emetic Symptoms

No or mild nausea with no active vomiting 2

Transient vomiting or retching 1

Persistent moderate to severe nausea and vomiting 0

TOTAL SCORE 14

CONTINUE

A minimal score of 12 (with no score less than 1 in any individual category) is required for a patient to bypass the postanesthesia care unit ("fast-tracked") after general anesthesia.

Admitting a postoperative patient directly to a less acute PACU environment from the operating room is called "fast tracking”

Slightly different criteria apply for determining "home readiness" (Table 36-3)

Eating or drinking successfully is seldom a criterion for discharge unless the patient has diabetes mellitus, has a long trip home, or is at risk for dehydration

Forcing food often leads to PONV

TABLE 36-3 CRITERIA FOR DETERMINATION OF A DISCHARGE SCORE FOR RELEASE HOME TO A RESPONSIBLE ADULT

Variable Evaluated Score

Vital signs (stable and consistent with age and preanesthetic baseline)

Systemic blood pressure and heart rate within 20% of preanesthetic level

2

Systemic blood pressure and heart rate within 20% to 40% of preanesthetic level

1

Systemic blood pressure and heart rate >40% of preanesthetic level

0

Activity level

Steady gait without dizziness or meets preanesthetic level 2

Requires assistance 1

Unable to ambulate 0

Nausea and vomiting

None to minimal 2

Moderate 1

Severe (continues for repeated treatment) 0

PATIENTS ACHIEVING A SCORE OF AT LEAST 9 ARE ACCEPTABLE FOR DISCHARGE

Variable Evaluated Score

Pain (minimal to no pain, controllable with oral analgesics)

Yes 2

No 1

Surgical bleeding (consistent with that expected for the surgical procedure)

Minimal (does not require dressing change) 2

Moderate (up to two dressing changes required) 1

Severe (more than two dressing changes required) 0

POSTOPERATIVE INSTRUCTIONS Before discharge reviewing the postoperative

instructions for wound care, medications, and return to activities and telephone contact

information for questions and emergencies Distinguishing expected postoperative symptoms

from more important complications Most facilities ask that surgeons give patients

prescriptions for postoperative medications before the time of surgery so that such medications can

be obtained before the trip home Giving a "starter pack" containing enough oral

analgesics for the first night

COMMON POSTOPERATIVE PROBLEMS

most common reasons for protracted stay in the PACU :

- PONV - pain - drowsiness Urinary retention in those at risk may also

delay discharge The unanticipated postoperative admission

rate to the hospital is less than 1%.

PATIENT EXPECTATIONS A patient's expectations of the postoperative period should be

realistic reassuring the patients that efforts to control pain and PONV

will not stop after discharge Mental clarity and dexterity may remain impaired for as long

as 24 to 48 hours despite an overall feeling of well-being Important decisions, driving an automobile, or operation of

complex equipment should not be attempted during this period

Discouraging the ingestion of alcohol or depressant drugs because of additive responses with residual anesthetic effects The diet should initially consist of clear liquids and progress to easily digested food (soups, cereal) and then a regular diet

as tolerated. Complications need to be addressed immediately and

dissatisfaction addressed in a timely and appropriate manner