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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