AMBULATORY SURGERYREFINING THE EXPERIENCE

Dr. Kenneth DickieRoyal Centre of Plastic Surgery

Measurement of Outcomes of Elective Surgery

• Health Related Quality of Life (HRQOL)• Patients self reported HRQOL for specific

elective surgical procedures is a more valid outcome measure than a surgeons own impression of outcome

• Objective assessments must incorporate the patient’s view of the impact of the procedure on their HRQOL

Emotional and Physical Reactions from Plastic Surgery

• Physical Reactions– Patients must be aware of nature’s “healing

curve”– Timetable for swelling, bruising, tightness, and

numbness must be re-enforced – 4 weeks to “looking good”– 3 months to “healed”

OUTPATIENT SURGERY

• Plastic Surgery procedures • 80% are performed as day surgery

procedures• Majority are ASA class I and II • Can we refine the patient experience?

Pre-Operative Preparation

• Patient information and informed consent– General information– Specific information

– Smoking and increased surgical risks– Thrombosis risk factor assessment– Emotional & Physical reactions from Plastic Surgery

Smoking and Increased Surgical Risk

• Nicotine –vasoconstriction may compromise circulation to tissue– Facelift– Breast Reduction– Abdominoplasty– Free tissue transfers and skin flaps

Stop Smoking

• One month prior to surgery• Two weeks after surgery• Patient must sign “Smoking and Increased

Surgical Risks” form• Cancel surgery if still smoking

Thrombosis Risk Factor Assessment

• Low risk—T.E.D. stockings + early ambulation

• Moderate risk- T.E.D. stockings +Sequential Compression Device or Anticoagulant

• High risk- T.E.D. stockings + SCD + Anticoagulant

Sequential Compression Device

• Surgery over 1 hour and patient over 40 places patient in moderate risk category for DVT

• Routine use of SCD in Plastic Surgery procedures

Oral Contraceptives and DVT

• Increased risk with oral contraceptives and hormone replacement therapy

• Stop BCP/HRT therapy (if possible) 1 cycle pre-op and 1 cycle post op

• Informed consent regarding DVT and Pulmonary Embolism

Emotional and Physical Reactions from Plastic Surgery

• Emotional Roller Coaster– Low point day 3 to 4– Support person crashes end of first week– Feeling good by end of 2nd week– Office staff must not “abandon” patient

Postoperative Recovery

• Hypothermia (core temp < 36 C.)– Over 70% of post op patients are hypothermic (depressed

thermoregulation, exposure, IV fluids, skin preps)– Results in:

• ^ Oxygen consumption post op (shivering)• ^ Cardiac output, hypertension, PVC’s, and arrhythmias• ^ Patient discomfort = ^ Narcotic requirement• LONGER STAYS IN THE RECOVERY ROOM

Hypothermia

• Patient Warming System– Surrounds the patient with warm air at desired

temperature:• Low 30-34 degrees• Medium 36-40 degrees• High 42-46 degrees

Patient Warming System

• Use intra-operatively for procedures longer than 2 hours

• Use postoperatively for procedures longer than 1 hour

• In ALL cases, there is a dramatic reduction in narcotic requirement, post operative nausea and vomiting.

• In ALL cases, there is an enhanced speed of post operative stabilization of the patient.

Patient Warming System

Postoperative Recovery

• ZOFRAN (Ondansetron HCl)– 4mg I.V. q4hr. Prn– Marked reduction in post operative nausea and

vomiting– Increased comfort for the patient– More rapid discharge following Day Surgery

Postoperative Recovery

• Nerve Blocks– Peripheral nerve blocks with long acting

anaesthetics (Marcaine) provide enhanced patient comfort and facilitate earlier discharge

– Reduced requirements for narcotics postoperatively

– May be performed by the anesthesiologist or surgeon while the patient is still under anaesthesia

Prophylactic Vasodilators

• Healing complications are one of the leading causes of litigation in Plastic Surgery

• “High Risk” zones benefit from proactive management with topical vasodilators

• Breast Reduction (nipple ischemia), Abdominoplasty (skin flap ischemia), Facelift (skin flap ischemia), any tissue with impaired blood supply.

Prophylactic Vasodilators

• Nitro-Dur patch: 0.4 or 0.6 mgm patch• Patients initial reaction to medication must be

monitored in the recovery room• Patches are applied at completion of surgery

and may be easily removed if BP problems develop (unusual)

• Patients may apply patch every 12 hours if ischemia persists

Prophylactic Antibiotics in Elective Plastic Surgery

• Any surgery greater than 2 hours in length• Any surgery where circulation to tissue is

compromised as a result of the surgical procedure– Breast Reduction– Abdominoplasty– Facelift– Selected Reconstructive Procedures– (any situation where prophylaxis is indicated for medical

reasons)

If you have any questions, feel free to contact Dr. Kenneth Dickie at royalcentreofplasticsurgery.com

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